Patient-Centred Innovations for Persons With Multimorbidity - Quebec

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 3 other provinces: British Columbia (BC); Manitoba (MB); and Nova Scotia (NS). 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

Interventions

BEHAVIORAL

DIMAC02

Integrated Approach For Chronic Diseases (DIMAC02) is an integrated approach for chronic disease prevention and management services that aims to improve and coordinate different regional initiatives in 11 Family Medicine Groups(FMG) related to : Self-management, Case management, Patient-centred care for persons with multimorbidity, Motivational approach, Interprofessional collaboration. DIMAC 02 specific objectives are: 1) To make available, in FMG's, an interdisciplinary educational intervention for prevention and management of chronic diseases for patients with low and high risk for complication. 2) To Increase the flow of communications between FMG and hospital facilities to improve continuity of care.

Sponsors & Collaborators

• Canadian Institutes of Health Research (CIHR)

  collaborator OTHER_GOV

• Western University, Canada

  collaborator OTHER

• Agence de la Sante et des Services Sociaux du Saguenay-Lac-Saint-Jean

  collaborator OTHER

• Université de Sherbrooke

  lead OTHER

Principal Investigators

• Martin Fortin, MD, M.Sc · Université de Sherbrooke

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

2016-04-22

Primary Completion

2022-11-01

Completion

2022-11-01

Countries

• Canada

Study Locations