Background: Epilepsy is the most common chronic
neurological illness worldwide, affecting more than 330, 000 people in
Canada, 10, 000 of which reside in the Ottawa area. Despite facing higher
mortality, stigma and social barriers, PLE (people living with epilepsy)
incur treatment gaps even in high income countries like ours. Our goal was
to address this burden locally with the creation of novel,
community-integrated, care delivery for PLE in our area; we describe its
inception. Methods: A transition program bridging
pediatric and adult institutions was created to address the care continuity
gap in 2017. Following a meeting of key stakeholders in the region in 2019,
the community group was integrated into the model of care and the city-wide
program was created incorporating adult, pediatric, transition and community
pillars. A patient friendly website was launched in 2020
(ottawaepilepsyprogram.ca). Results: 170 patients
were followed in the transition program since 2017. Adult and pediatric
pillars have referred 70 patients to the community program between
2019-2020, 48 between 2020-2021. Through this, PLE are able to access the
Clinic to community (C2C) and UPLIFT programs for social support services
and mental health, respectively. Conclusions: An
interconnected region-wide program can support PLE and foster innovative
care integration across disciplines.