Grant: Operating Grant: SPOR Innovative Clinical Trial Multi-Year Grant

Some patients who have multiple long-term health conditions have significant challenges in accessing needed services despite available primary care and social services resources. Patient navigation programs may help those with complex health conditions improve their care and outcomes and if delivered by community health workers (CHWs) who have close community ties, these programs have the potential to reduce barriers to care and increase access to coordinated, person-centred care. The University of Calgary's ENCOMPASS program aims to improve the care and health outcomes for high-risk patients by linking patients with chronic disease with a CHW to help them navigate the health system, facilitate communication between patients and providers, improve patients' understanding of their conditions and treatment plans, and support patients in their self-management. In Canada, patient navigation programs have not been well studied or broadly implemented in patients with chronic disease, making a comprehensive evaluation of ENCOMPASS important. This program has great potential to improve care for patients with chronic diseases in Alberta's primary care system. A key element of ENCOMPASS is that patients have been involved in all stages from planning, to pilot testing, to implementation. Given the increasing popularity of patient navigation/CHW programs in other Canadian provinces as well as in the United States, the results of the proposed research will have value outside Alberta.