Grant: Fellowship: POR Awards - Transition to Leadership Stream - Phase 1

Patients with complex care needs are at high-risk of low-quality care resulting in poor health outcomes. Improving care for high-needs patients while managing health system costs is a challenging but important priority for patients, providers, and policymakers. Patients with complex care needs include individuals with advanced illness near the end of life, frail older adults, and patients with serious mental illness, and are high-cost users of health services. In Canada, just 5% of patients account for over 60% of hospital and nursing home costs. In many cases high costs and poor outcomes for patients could be avoided with the right supports at the right time. Patient-oriented health economics research is an approach which can help develop critical evidence on how to avoid the drivers of high cost use and improve outcomes for patients. In this fellowship project I will collaborate with patient partners with complex care needs and their 'circle of care' to: a) develop methods to predict individuals at high risk of becoming future HCUs, and b) investigate patients' perceptions and attitudes toward their complex care needs and supports available to improve their care. To identify persons at-risk of becoming high-cost users, I will use routinely collected health data from BC. For this study, routinely collected data will include administrative data as well as newly available data from surveys of recently discharged hospital patients. These surveys are unique to BC, and asked patients to describe their health and experience in hospital. I will then conduct one-to-one interviews with high-cost users to understand which supports at what time could be helpful in preventing costly episodes of care and improving their outcomes.