Grant: Embedded Clinician Researcher Salary Award - Central Canada

Transitions from one sector of the health care system to another are the most dangerous and vulnerable periods for patients and caregivers. Therefore, improving transitions and related experiences is a major focus of quality improvement in most health jurisdictions within Ontario, Canada and globally. Because transitions involve care across different providers, it is essential to use a patient perspective and measure individuals' transitions over time. Further, in order to improve transitions of care, it is necessary to understand the contextual factors surrounding transitions throughout transitions of care. Addressing this important health system issue, in partnership with Health Quality Ontario, this research program aims to: (1) characterize trajectories for complex populations through patient-centred episodes of care using administrative health data; (2) understand patient, caregiver, provider and decision-maker experiences for health system performance improvement using qualitative methods; and (3) identify and evaluate quality improvement interventions to optimize transitions in care for complex populations. Given rising health care costs, it is increasingly important to provide efficient value-based health care that is needs driven for specific populations across the continuum of care. Working with Health Quality Ontario, this innovative research will inform opportunities for system improvement for targeted intervention, such as the creation of potential payment bundling options for care episodes among different complex populations. In understanding trajectories for persons with complex needs, transformational models of care can be co-created with patients and providers to encompass the entire anticipated expected trajectory of care for optimal service delivery and outcomes.