Grant: Team Grant: Community-Based Primary Healthcare - LOI

Canada has an aging population with many patients who have more than one chronic condition. Health services today continue to struggle in providing care for this population, particularly those living in small urban, rural, and northern communities. This research will develop and test an innovative program for chronic disease management and prevention of chronic conditions. We will study current programs in Alberta, British Columbia, and Yukon to determine what works well, and what improvements are required. This information will be used to develop a set of principles for care delivery for chronic disease management. These principles will then be put into practice in three areas across the three provinces and territories involved. We will then measure patient, provider, and health system outcomes. The involvement of patients in their care, as well as involving patients and citizens in service planning, will be an important focus of the research. We will also look at ehealth (e.g., phone apps) to assist patients in managing their care. Managers, healthcare providers, patients, and community organizations will be involved in the study. The findings from this innovative research will be used to improve chronic disease prevention and management in small urban, rural, and northern communities in Alberta, British Columbia, and Yukon. It will also provide important information that can be used by patients, providers, and decision-makers to design and deliver chronic disease management services in rural and northern areas across Canada and internationally. For patients, this research will assist in improving outcomes for the increasing number of Canadians with chronic disease.