Care transitions in and out of hospital are increasingly the target of health system reform in Canada. Despite the focus on care transitions, few interventions have been found to reduce readmissions or costs. Integrated models of care (IC) are evidence-based models aimed at improving the patient, caregiver and care provider experience, with a focus on creating a seamless care experience for the patient across the health continuum. Our project will adapt, spread and evaluate an IC model successful implemented in Ontario to patients with multimorbidity and seniors with complex care needs in Toronto and Alberta on quintuple aims.
This is a five year funded project with a large group of co-investigators from Toronto and Calgary, presenting several opportunities for graduate-level projects.
We are currently seeking graduate students who are interested in leading projects focused on care transitions, and:
- Comparison of frailty and risk assessment scales at point of care
- Application of Sex/gender and intersectionality frameworks for evaluation of integrated care
- Impact of new care models on clinician burnout