Grant: Team Grant - SPOR iCT Rewarding Success - Phase 3 - Alberta

Caring for patients with advanced-stage diseases is a growing challenge in Canada. Care is uncoordinated with high rates of hospitalization, and aggressive use of treatments towards the end of life, despite limited benefit. Care often does not reflect patients' preferences and is associated with poor outcomes and quality of life. Integrated community- and home-based care aligned with patients' preferences is essential to improving patient outcomes. The use of clinical pathways is effective in integrating care and optimizing patient outcomes. The implementation of a Conservative Kidney Management (CKM) pathway across Alberta for patients with end-stage kidney disease (ESKD) who were unlikely to benefit from dialysis has improved symptoms, increased patient satisfaction, and reduced costs for these patients. This study aims to build on the success of the CKM Pathway by adapting and spreading the Pathway to include patients with advanced cancer and heart, lung, and liver failure. This newly co-designed interactive, on-line Supportive Care Pathway will have health care provider and patient portals to navigate the pathway and access patient education resources, interactive decision aids, and management strategies appropriate for an individual's needs and preferences. This Supportive Care Pathway will be implemented within primary care clinics across Alberta. The effect of the Pathway on patient outcomes and quality of life will be evaluated along with its cost effectiveness. We anticipate high uptake of the Pathway resulting in care that is more consistent with patients' preferences, improved patient outcomes, greater satisfaction with care, and reduced costs across the health system. We anticipate that health care providers will have greater satisfaction with the care they provide using the Pathway. This project will set a benchmark nationally and internationally and will serve as a model for pathway development for patients with advanced-stage diseases.