Grant: Team Grant: TiC - Stream 1 - PHSI solutions for transitions in care gaps

Transition in care (TiC) refers to the complicated processes that help coordinate the continuation of services as people experience changes in their health, care needs and where they receive care. Poor coordination of TiC can cause additional health issues, causing more problems such as trips to the emergency department and/or being re-admitted to the hospital. This is very expensive for the patient, their family, and the health care system, and can lead to more health concerns. When someone has a lifelong condition, they have multiple TiC because their needs change over time. A good example of this are those who have a spinal cord injury (SCI). In Alberta, the provincial SCI community (patients, clinicians, decision makers, community partners, researchers) has been working together since 2016, and has agreed that improving TiC for persons with SCI is most important, knowing that other groups with lifelong conditions face similar challenges. Our provincial research team plans to carry out a 4 year project that will create and test a new model for TiC which will be part of a larger provincial "hub and spokes system". The "hub" sites are Calgary and Edmonton (where the SCI specialty services are) and the "spoke" sites will be Lethbridge and Slave Lake, since many patients are discharged there from the hubs. We will measure the impact this new model has on patient health, experiences and well-being, the use of health care services and associated costs. In fact, early analysis by the Alberta Health Services showed that reducing emergency department visits by persons with SCI by 11% we will save $1M per year! Our plan matches the focus of this funding opportunity, as it includes people who are at risk for poor TiC, such as those living in rural and remote areas, and Indigenous Peoples. We will learn together to find ways to improve TiC for persons with SCI, measure its impact and share and expand the TiC model through provincial and national partnerships.