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

The goal of the CARE-CORE Team (Coordinated Primary Care and Chronic Disease Management for High Healthcare Utilization Patients in the Urban Core) is to improve the coordination of care between family doctors, specialists, and community care providers for vulnerable patients living in Canadian cities. The research team is focused on patients who suffer from numerous chronic illnesses, addictions, and/or mental illness. These individuals frequently visit the emergency department or get admitted to the hospital. The team's goals are to improve the health and healthcare of these individuals, and reduce their use of emergency rooms and hospitals.The CARE-CORE Team will try to achieve these goals by developing methods to identify individuals who are expected to be high users of emergency departments and hospitals. The Team will then test new interventions and models of care to see if they are effective in helping these patients. Many of these interventions and models of care are based on improving communication and coordination among the many care providers for these complex patients. This effort has the potential to benefit both disadvantaged members of society and the health care system as a whole.