scholarly journals Proceedings of the inaugural Canadian Healthcare Navigation Conference: a forum for sharing innovations and best practices in navigation services

2021 ◽  
Vol 15 (S16) ◽  
Author(s):  
R. Markoulakis ◽  
A. Luke ◽  
A. Reid ◽  
K. Mehra ◽  
A. Levitt ◽  
...  
Keyword(s):  
Lived Experience ◽  
Barriers To Care ◽  
Service Providers ◽  
Medical Professional ◽  
Lessons Learned ◽  
Complex Care ◽  
Care Needs ◽  
Care Plans ◽  
Complex Care Needs ◽  
Canadian Healthcare

Abstract Background Individuals experiencing chronic illnesses face many physical, emotional, and social strains as a result of their illnesses, all the while trying to navigate unfamiliar territory in the healthcare system. Navigation is a strategy that can help people facing complex care needs and barriers to care in finding and accessing needed supports in the health care system. Navigators provide a patient-centred service, guiding individuals through their care plans and overcoming barriers to care. Navigation supports for individuals experiencing complex care needs have shown significant promise and have been gaining traction across Canada. Methods The Canadian Healthcare Navigation Conference was the first event of its kind in Canada to bring together navigation researchers, service providers, students, decision makers, and individuals with lived experience to share lessons learned, promising practices, and research findings. This event was co-hosted by the Family Navigation Project at Sunnybrook Health Sciences Centre and NaviCare/SoinsNavi at the University of New Brunswick, and took place virtually on April 15–16, 2021. Results This event spanned two days, which both began with a keynote address, one from a researcher and medical professional in navigation, and another from an individual with lived experience involved in advocacy in Canadian healthcare. Concurrent oral presentations by a variety of presenters were held following each keynote presentation. A poster session was held at the end of the first day, and a panel presentation rounded out the second day. Concurrent and poster presentations covered a range of topics pertaining to approaches to navigation, navigator roles, evaluation and quality improvement, lived experience in navigation, and navigation in the context of the COVID-19 pandemic. The panel presentation focused on identifying how the navigation field has progressed in Canada and identifying crucial next steps in navigation. These next steps were determined to be: 1) agreement on navigation-related definitions, 2) regulation and training, 3) equity, diversity, inclusion, and accessibility, 4) integrating lived experience, and 5) regional coordination. Conclusion This conference was an important first step to creating a shared national conversation about navigation services so that we can continue to develop, implement, and share best evidence and practices in the field.

scholarly journals A Transitional Care Model for Veterans With Complex Needs During COVID: The Behavioral Recovery Outreach (BRO) Team

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 46-46
Author(s):  
Kathleen Matthews ◽  
Latrice Vinson
Keyword(s):  
Transitional Care ◽  
Lessons Learned ◽  
Future Research ◽  
Complex Care ◽  
Veterans Health ◽  
Behavioral Recovery ◽  
Care Needs ◽  
Program Outcomes ◽  
Complex Care Needs ◽  
Team Model

Abstract The Veterans Health Administration’s Care for Patients with Complex Problems (CP)2 Program developed a national infrastructure to disseminate promising practice models to improve care for Veterans with complex medical, mental health, and/or neurocognitive conditions, who may also have behaviors disruptive to care. A strategic priority is improving safe and effective transitions to community care for Veterans with complex care needs, many of whom have historically been limited to VA settings as a result of behavioral concerns. The Behavioral Recovery Outreach (BRO) Team was the first model identified for national dissemination and evaluation at partner sites. Developed at VA Central Iowa, BRO is an interdisciplinary team model that identifies Veterans in long-term VA care settings with complex care needs to engage in individualized behavioral programing to manage/stabilize behaviors and safely transition them to more appropriate and less costly community settings. This symposium will describe the BRO team model, highlight the facilitators and barriers to nationally disseminating the BRO model with VA partner facilities, discuss adaptations in continuing community transitions following the COVID-19 pandemic, and describe program outcomes. The first speaker will discuss development of the BRO model and outcomes of a regional dissemination. The second speaker will present results from the program evaluation of the national dissemination. The final speaker will describe BRO Team expansion and lessons learned from the perspective of a VA partner facility. The (CP)2 Program Director will integrate findings and highlight implications for scaling and evaluating promising models for national dissemination for policy, practice, and future research.

scholarly journals Engaging Older Veterans With Serious Mental Illness in Physical Activity: In-Person, Remote, and Hybrid Models

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 205-206
Author(s):  
Sera Havrilla ◽  
Alicia Lucksted ◽  
Deborah Medoff ◽  
Karen Fortuna ◽  
Amanda Peeples ◽  
...  
Keyword(s):  
Physical Activity ◽  
Older Adults ◽  
Mental Illness ◽  
Lived Experience ◽  
Serious Mental Illness ◽  
Complex Care ◽  
Care Needs ◽  
Coaching Intervention ◽  
Peer Specialists ◽  
Complex Care Needs

Abstract Older adults with serious mental illness (SMI) have complex care needs across medical, psychiatric, cognitive, and social domains. This growing population exhibits high levels of medical comorbidity and sedentariness. Innovative interventions that promote holistic recovery for this group are needed, especially in the context of the COVID-19 pandemic. Peer Education on Exercise for Recovery (PEER) is a peer coaching intervention, delivered by VA Peer Specialists (Veterans with lived experience of mental illness), to promote exercise and physical activity among older adults with SMI. This paper will present on three different models of PEER: fully in-person, fully remote, and a hybrid model with both in-person and remote elements. Preliminary data indicates that PEER is (1) engaging and well-liked, (2) associated with greater sustained increases in physical activity compared to an active control, and (3) can lead to sustained physical activity increases that are resilient to situational constraints such as physical distancing.

Health Status Transitions in Community-Living Elderly with Complex Care Needs

2011 ◽  
pp. 223-247
Author(s):  
Louise Lafortune ◽  
François Béland ◽  
Howard Bergman ◽  
Joël Ankri
Keyword(s):  
Health Status ◽  
Community Living ◽  
Complex Care ◽  
Care Needs ◽  
Complex Care Needs

scholarly journals People with an intellectual disability in the discourse of chronic and complex conditions: an invisible group?

2008 ◽  
Vol 32 (3) ◽  
pp. 405 ◽  
Author(s):  
Linda Goddard ◽  
Patricia M Davidson ◽  
John Daly ◽  
Sandra Mackey
Keyword(s):  
Health Care ◽  
Intellectual Disability ◽  
Chronic Conditions ◽  
Health Professions ◽  
Disability Services ◽  
Complex Care ◽  
Competency Development ◽  
Care Needs ◽  
Complex Care Needs ◽  
Respiratory Conditions

People with an intellectual disability and their families experience poorer health care compared with the general population. Living with an intellectual disability is often challenged by coexisting complex and chronic conditions, such as gastrointestinal and respiratory conditions. A literature review was undertaken to document the needs of this vulnerable population, and consultation was undertaken with mothers of children with disabilities and with professionals working within disability services for people with an intellectual disability and their families. Based on this review, there is a need to increase the profile of people with an intellectual disability in the discourse surrounding chronic and complex conditions. Strategies such as guideline and competency development may better prepare health professions to care for people with disabilities and chronic and complex care needs and their families.

scholarly journals Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study (Preprint)

2020 ◽  
Author(s):  
Carolyn Steele Gray ◽  
Terence Tang ◽  
Alana Armas ◽  
Mira Backo-Shannon ◽  
Sarah Harvey ◽  
...  
Keyword(s):  
Older Adults ◽  
Phase 1 ◽  
Care Transitions ◽  
Self Management ◽  
Complex Care ◽  
Phase 2 ◽  
Care Needs ◽  
Centered Care ◽  
Hospital To Home ◽  
Complex Care Needs

BACKGROUND Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. OBJECTIVE This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. METHODS The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. RESULTS This project is underway and expected to be complete by Spring 2024. CONCLUSIONS Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. CLINICALTRIAL ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/20220

scholarly journals Do general practice management and/or team care arrangements reduce avoidable hospitalisations in Central and Eastern Sydney, Australia?

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Heidi Welberry ◽  
Margo Linn Barr ◽  
Elizabeth J. Comino ◽  
Ben F. Harris-Roxas ◽  
Elizabeth Harris ◽  
...  
Keyword(s):  
General Practice ◽  
Data Collection ◽  
Health Service ◽  
Baseline Period ◽  
Health Service Utilisation ◽  
Service Utilisation ◽  
Complex Care ◽  
Care Needs ◽  
Team Care ◽  
Complex Care Needs

Abstract Background The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management program was introduced to Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The program supports General Practitioners (GP)s claiming for up to one general practice management plan (GPMP) and one team care arrangement (TCA) every year and the patient claiming for up to five private allied health visits. We describe the profile of participants who claimed for GPMPs and/or TCAs in Central and Eastern Sydney (CES) and explore if GPMPs and/or TCAs are associated with fewer emergency hospitalisations (EH)s or potentially preventable hospitalisations (PPH)s over the following 5 years. Methods This research used the CES Primary and Community Health Cohort/Linkage Resource (CES-P&CH) based on the 45 and Up Study to identify a community-dwelling population in the CES region. There were 30,645 participants recruited within the CES area at baseline. The CES-P&CH includes 45 and Up Study questionnaire data linked to MBS data for the period 2006–2014. It also includes data from the Admitted Patient Data Collection, Emergency Department Data Collection and Deaths Registry linked by the NSW Centre for Health Record Linkage. Results Within a two-year health service utilisation baseline period 22% (5771) of CES participants had at least one claim for a GPMP and/or TCA. Having at least one claim for a GPMP and/or TCA was closely related to the socio-demographic and health needs of participants with higher EHs and PPHs in the 5 years that followed. However, after controlling for confounding factors such as socio-demographic need, health risk, health status and health care utilization no significant difference was found between having claimed for a GPMP and/or TCA during the two-year health service utilisation baseline period and EHs or PPHs in the subsequent 5 years. Conclusions The use of GPMPs and/or TCAs in the CES area appears well-targeted towards those with chronic and complex care needs. There was no evidence to suggest that the use of GPMPs and /or TCAs has prevented hospitalisations in the CES region.

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