Grant: Operating Grant: Transitions in Care - Evaluation Grants

Background: Many jurisdictions in Canada and worldwide have implemented coordinated care plans (CCPs) to support "high cost" patients with healthcare system navigation, and to influence social determinants of health. However, evaluations of the effectiveness of CCPs have found mixed results. Goals: For the Southeastern region of Ontario as a single case study design, the following questions will be answered: i) what is the impact of CCPs on enrolled patients compared to a control group with respect to healthcare utilization and costs? and ii) what are the factors that influence CCP benefits and costs, through asking decision-makers, CCP managers, healthcare providers, patients and their families about their individual experiences? Methods: ,An exploratory design that integrates resource utilization data and individual experiences with the healthcare system will be used. Data from the South East Health Integrated Information Portal will be linked with data from the Institute of Clinical & Evaluative Sciences. An Advisory Committee will guide the project. Expected outcomes: The results of this study will be used as a model to assist all regions in improving coordinated care programs, and will help inform decisions about resource allocation to integrated health programs for "high cost" patients in the transitions in healthcare.