Grant: Project Grant

Caring for complex patients often with multiple chronic conditions is one of the biggest challenges facing our healthcare system. These patients are managed through siloed specialists and other providers, which can lead to suboptimal clinical management, poor outcomes, and poor patient experiences. While 75% of healthcare dollars are dedicated towards the management of chronic illnesses, more than 50% is consumed by complex patients, who make up only 5% of the population. The high costs are mainly due to patients repeatedly getting admitted to hospital after discharge. This project will explore how to best implement a Virtual Integrated Complex Care Clinic and the impact of the Clinic on patient outcomes including rehospitalizations. The Clinic will include a nurse-led model of integrated care, and telemonitoring. A nurse-led integrated care model means a nurse (or nurse practitioner) is the central point person to communicate with the patient and their care team to plan and execute a care plan that accounts for all of the patient's health conditions, thereby breaking down the current siloed care. However, even with a nurse-led integrated care model, the complex patients could get worse between visits to the clinic without the nurse knowing, and frequent visits to the clinic can be hard especially for these who are very sick. Telemonitoring enables patients to track important measurements (for example, blood pressure and weight) and symptoms at home, and to send this information to their clinicians so they know their patients' health status between clinic visits. The nurse can act on the information before patients are so sick that they need to be admitted to hospital again. This will be the first study to combine a nurse-led integrated care model and telemonitoring into a clinic to help complex patients as they transition from hospital to home. It may provide evidence to support a new scalable way to help complex patients stay out of the hospital.