Grant: Oper Grant:eHealth Innov Partnership Program(eHIPP)-Seniors w Complex Care Needs

One of the chief goals of aging-related medicine and research is to enhance and maintain quality of life within environments of choice through the identification of early changes in health and functioning, and to offer appropriate and efficient early interventions before serious limitations or morbidities develop. Changes in physical condition, neurocognitive status, functional capacity, and ability to carry out health-promoting or maintaining activities require regular monitoring to better match the array of treatments and supports to the patient's changing spectrum of requirements. This project evaluates the role of integrated electronic patient-reported outcome measures (PROs) and patient-demonstrated behaviours in a home environment to gauge care needs and supply near real-time feedback to the patient, formal and informal caregivers, and clinicians. The objective is to optimize patient experience by readily identifying patient needs and risks and then taking action to provide better specified services to meet needs and manage risks. The longer-term objective is to maintain the home as a viable location for quality care for as long as possible - from the perspectives of patients and informal caregivers - and to minimize the potentially adverse impacts of poorly-anticipated and managed transitions to higher levels of care. This innovative eHealth solution will provide day-to-day information about the lived experiences and practices of patients with complex care needs living independently; evaluate the role of real-time feedback to clinicians, caregivers, and patients to gauge care needs, quality of care and patient experience; and enable delivery of more efficient and effective care by aligning care needs appropriately with health care resources, thereby enhancing system responsiveness to individualized needs.