Grant: Fellowship: Health System Impact Fellowships - Western Canada 1 year

Two important challenges that face the Canadian health care system are population aging and increasing prevalence of chronic diseases. The province is increasing its efforts to strengthen primary health care and improve access to comprehensive, integrated, patient-centered, culturally responsive care in community settings. This will better respond to an aging population who require chronic complex care. The Saskatoon Health Region will implement a local community designed, team based collaborative care model to improve access to appropriate care with a focus on older adults in community based settings. The model will build on existing services and address gaps in service provision in the pilot community site. This proposal will evaluate the implementation of the local collaborative care model in a high need community of aging adults. It will help us to understand how best to achieve high functioning team-based care in community settings and examine successes, challenges and service outcomes of implementation. Multiple sources of data and methods will be employed including interviews, surveys and models to understand the various participant experiences and effects on service utilization.The lessons learned will guide future local efforts to provide more effective collaborative community based care.