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

NCT06679309 | Not Yet Recruiting

• 2 other identifiers: REB23-1442202211IS6
• Study Type: interventional
• Target: 2,000
• Locations: 1 country
• Sites: 1

Brief 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:

• 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:
• To adapt and implement the ICP in Calgary's 4 hospitals over a 3 year period.
• To evaluate the implementation of the ICP in Calgary leveraging the Quintuple Aim Framework.
• How patients and their caregivers experienced their time in hospital and transition home.
• How healthcare providers feel about the ICP's impact on patient care.
• The ICP's impact on patient health outcomes,
• The use of hospital resources, and the cost of providing care.
• The ICP's impact on equity, or fair access to healthcare resources and services.

Conditions

Health Care Quality, Access, and Evaluation

Keywords

integrated care; patient experience; provider experience; continuum of care; medical vulnerability; social determinants of health; psychosocial vulnerability

Outcome Measures

Primary Outcomes (1)

• Patient experience

  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 ,.

  From enrollment to 90 days post-discharge

Secondary Outcomes (1)

• Re-admission

  up to 3 months after discharge

Other Outcomes (1)

• Quintuple Aim - a conceptual framework for evaluating quality of healthcare services developed by the Institute of Healthcare Improvement for evaluating new health programs

  minimum 6 months post-implementation of ICP at all sites

Study Arms (1)

Integrated care pathway supported by the integrated care lead

EXPERIMENTAL

Enrolled patients in the ICP will then undergo more assessment by the Integrated Care Lead to develop a preliminary inventory of their needs for transitioning back to their health home. Patients will then be assigned an Integrated Care Lead with expertise in managing their particular needs. This will result in the development of a complex care plan that is co-designed with a patient's acute and community care team (eg: primary care, home care, community services, hospital medical team etc). This plan will be documented in Connect Care and incorporated into the discharge summary at the time of hospital discharge. (see Appendix 2) Calgary Zone Integrated Care Program will then provide: * Continuity of care with the assigned ICP team member(s) throughout their hospitalization and connection with community resources and services in the process of complex discharge planning. * Efficient use of healthcare resources by reducing duplication of services and systematically screening for unmet

Other: Integrated care plan

Interventions

Integrated care plan OTHER

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

Integrated care pathway supported by the integrated care lead

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• PATIENTS:
• Over 18 years of age
• Able to provide informed consent, or has substitute-decision-maker and is able to provide assent.
• Resides in Calgary Zone
• 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
• 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.
• Community-dwelling
• CAREGIVER
• 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)
• Provides informed consent to participate in the study.
• PROVIDERS
• 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)
• Provides informed consent to participate in the study

You may not qualify if:

• \) 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
• \) 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
• \) Non-hospital medicine populations
• Pediatric (17 years or younger)
• Admitted to surgery, obstetrics/gynecology
• Admitted to a psychiatric ward

Sponsors & Collaborators

• University of Calgary: lead
• Canadian Institutes of Health Research (CIHR): collaborator

Study Sites (1)

University of Calgary

Calgary, Alberta, T2V 5A8, Canada

Location

Related Publications (11)

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Study Officials

• Michelle Grinman, MD FRCPC MPH

  University of Calgary

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Michelle Grinman, MD FRCPC MPH

CONTACT

‭403-943-3889; michelle.grinman@ucalgary.ca

Harpreet K Jaswal, MPH

CONTACT

647-390-9661; harpreet.jaswal1@ucalgary.ca

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NA
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: SINGLE GROUP
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: November 5, 2024
• First Posted: November 7, 2024
• Study Start: May 1, 2025
• Primary Completion (Estimated): December 1, 2028
• Study Completion (Estimated): December 31, 2028
• Last Updated: March 28, 2025

Record last verified: 2025-03

Data Sharing

• IPD Sharing: Will share

Locations

CA (1)