Grant: Catalyst Grant: Patient-Oriented Research

Coordinating care between providers in the hospital and the community is challenging. This challenge hampers the continuity of care for older adults who have complex health and social needs. There is limited evidence on how to best coordinate care for older adults transitioning from the hospital back to the community. Recently, several provinces have introduced two types of interprofessional teams that have potential to improve post-hospital care. One is community-based transitional care teams that provide rehabilitation and support services to promote post-hospital recovery. The second is networks of health and social care professionals that support family physicians. Hospital, community, and primary care teams need to work well together to address transitions in care. Otherwise, the addition of more teams to the health care system can further hamper coordination. Increasing the ability of health care teams to support transitions from hospital to home is a complex issue that requires the input of multiple stakeholders. Important stakeholders include patients and their families, health and social care professionals in hospital and community, and policymakers. Patients in particular, have not had their values and needs attended to in care transitions research. This project will engage all necessary stakeholders to collaboratively design a research study that will develop solutions for improving continuity between interprofessional teams. We will pilot the methods and evaluate the process we used to engage patients in the research process. The result will be a tested study protocol and participatory research process to support a successful national grant application. In the long-term, our work will propel practice change in how teams work across settings to support care transitions from hospital to home. Using the experiential knowledge of patients, families and care providers will make the research relevant to the people it will impact the most.