Grant: Project Grant

Adults with multiple chronic conditions who also suffer from mental health comorbidities and/or social vulnerability often have complex health and social care needs. Complex needs call for integrated care across providers, settings and sectors. A good understanding of care transitions across community, primary care, and hospital settings, remains crucial to implement models of integrated care such as case management or the patient-centered medical home. The goal of this study is to better understand care transitions of adults with complex health and social care needs across community, primary care, hospital settings. To this end, our PriCARE team of patients, clinicians, policy makers and inter-disciplinary researchers from Quebec (QC), New Brunswick (NB), and Newfoundland and Labrador (NL), will leverage our successful teamwork of the last four years to conduct a study in 6 health networks of these three provinces (2 per province). We will recruit 30 women and 30 men with complex needs in the emergency department of health network (total n=360) during the first year of the study. These participants will complete a questionnaire administered by phone at baseline and at 6 months to evaluate their experience of care transitions. In the second phase of the project, we will conduct: 1) individual semi-structured interviews with 4 women and 4 men per network, among participants and their family with the lowest and highest measures for care transitions; 2) focus groups (FG) of 6 participants with different providers in each network; and 3) individual semi-structured interviews with 8 managers per network. This study will deliver new scientific knowledge and empirical evidence on care transitions of patients with complex needs to inform research, healthcare policy and management, and practice, and increase knowledge and awareness among the general public.