Grant: Team Grant: Transitions in Care

Children and Youth with Special Healthcare Needs (CYSHCN) are those who have or are at increased risk for a chronic condition such as asthma, diabetes, sickle cell, and autism. They require many services and care providers, involving care transitions within and across care systems. These care systems include acute (emergency room and hospital admissions), secondary (specialists), primary (family doctors, nurses, community health centres), and community (schools, social services) care. Failing to effectively transition across care systems may result in adverse outcomes, including increased hospital visits, delays in services, caregiver stress, and school absences. Our proposal focuses on families of migrant CYSHCN (children and/or parent born outside of Canada) because they face many barriers that make them more at risk for poor transitions across care systems. These barriers include structural racism, language, and difficulties in navigating a complex healthcare system. Patient navigators have emerged from studies conducted by our team and others as a promising solution to address barriers during transitions in care. We therefore propose a trial that will examine the effectiveness of a patient navigator co-designed with stakeholders (parents/caregivers and clinicians) that will target modifiable barriers during transitions between acute, secondary, primary, and community care through the navigator's three core roles: 1) Navigating the healthcare system; 2) Care coordination; and 3) Cultural safety. We will test whether the patient navigator decreases barriers to care and improves care coordination, caregiver empowerment, caregiver stress, and healthcare utilization. At the end of the trial, we will interview participants to understand why the navigator may or may not have worked. Our team of patient partners, decision-makers (involved in policy and practice), clinicians, and researchers will ensure the spread and scalability of our intervention beyond the grant.