Patient-Centred Innovations for Persons With Multimorbidity - Ontario

Summary

The aim of Patient-Centred Innovations for Persons With Multimorbidity (PACE in MM) study is to reorient the health care system from a single disease focus to a multimorbidity focus; centre on not only disease but also the patient in context; and realign the health care system from separate silos to coordinated collaborations in care. PACE in MM will propose multifaceted innovations in Chronic Disease Prevention and Management (CDPM) that will be grounded in current realities (i.e. Chronic Care Models including Self-Management Programs), that are linked to Primary Care (PC) reform efforts. The study will build on this firm foundation, will design and test promising innovations and will achieve transformation by creating structures to sustain relationships among researchers, decision-makers, practitioners, and patients. The Team will conduct inter-jurisdictional comparisons and is mainly a Quebec (QC) - Ontario (ON) collaboration with participation from 4 other provinces: British Columbia (BC); Manitoba (MB); Nova Scotia (NS); and New Brunswick (NB). The Team's objectives are: 1) to identify factors responsible for success or failure of current CDPM programs linked to the PC reform, by conducting a realist synthesis of their quantitative and qualitative evaluations; 2) to transform consenting CDPM programs identified in Objective 1, by aligning them to promising interventions on patient-centred care for multimorbidity patients, and to test these new innovations' in at least two jurisdictions and compare among jurisdictions; and 3) to foster the scaling-up of innovations informed by Objective 1 and tested/proven in Objective 2, and to conduct research on different approaches to scaling-up. This registration for Clinical Trials only pertains to Objective 2 of the study.

Conditions

• Hypertension
• Depression
• Anxiety
• Musculoskeletal Pain
• Arthritis
• Rheumatoid Arthritis
• Osteoporosis
• Chronic Obstructive Pulmonary Disease (COPD)
• Asthma
• Chronic Bronchitis
• Cardiovascular Disease
• Heart Failure
• Stroke
• Transient Ischemic Attacks
• Ulcer
• Gastroesophageal Reflux
• Irritable Bowel
• Crohn's Disease
• Ulcerative Colitis
• Diverticulosis
• Chronic Hepatitis
• Diabetes
• Thyroid Disorder
• Cancer
• Kidney Disease
• Urinary Tract Problem
• Dementia
• Alzheimer's Disease
• Hyperlipidemia
• HIV
• Multimorbidity

Interventions

BEHAVIORAL

TIP / IMPACT Plus Care Coordination

The intervention will involve the patient attending an interdisciplinary team meeting, either through the Ontario Telemedicine Network's teleconferencing technology or in person, along with their caregiver(s), the referring practitioner, inter-professional (IP) teams and home care coordinators to discuss and uncover the patient's condition covering a diverse range of medical, functional and psycho-social issues and the development of a patient-centred treatment plan. The care plans are documented, shared, implemented and monitored by an assigned nurse from the program.

Sponsors & Collaborators

• Western University, Canada

  collaborator OTHER

• Université de Sherbrooke

  collaborator OTHER

• Canadian Institutes of Health Research (CIHR)

  collaborator OTHER_GOV

• Sunnybrook Health Sciences Centre

  collaborator OTHER

• Unity Health Toronto

  collaborator OTHER

• University Health Network, Toronto

  collaborator OTHER

• Michael Garron Hospital

  collaborator OTHER

• Providence Healthcare

  collaborator OTHER

• Mount Sinai Hospital, Canada

  collaborator OTHER

• Toronto Central Community Care Access Centre

  collaborator OTHER

• Women's College Hospital

  collaborator OTHER

• London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's

  lead OTHER

Principal Investigators

• Moira Stewart · Western University

Study Design

Allocation

RANDOMIZED

Purpose

OTHER

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

18 Years

Max Age

80 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2016-01-12

Primary Completion

2019-04-07

Completion

2022-10-19

Countries

• Canada

Study Locations