Abstract
BackgroundAdults with chronic conditions who also suffer from mental health comorbidities and/or social vulnerability require services from many providers across different sectors. They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. In response, the literature has stressed the need for a collaborative approach amongst providers to facilitate the care transition process. A better understanding of care transitions is the next step towards the improvement of integrated care models. The aim of the study is to better understand care transitions of adults with complex health and social care needs across community, primary care, and hospital settings, combining the experiences of patients and their families, providers, and health managers.Methods/designWe will conduct a two-phase mixed methods multiple case study (quantitative and qualitative). We will work with six cases in three Canadian provinces, each case being the actual care transitions across community, primary care, and hospital settings. Adult patients with complex needs will be identified by having visited the emergency department at least three times over the previous 12 months. To ensure they have complex needs, they will be invited to complete INTERMED Self-Assessment and invited to enroll if positive. For the quantitative phase, data will be obtained through questionnaires and multi-level regression analyses will be conducted. For the qualitative phase, semi-structured interviews and focus groups will be conducted with patients, family members, care providers, and managers, and thematic analysis will be performed. Quantitative and qualitative results will be compared and then merged.DiscussionThis study is one of the first to examine care transitions of adults with complex needs by adopting a comprehensive vision of care transitions and bringing together the experiences of patients and family members, providers, and health managers. By using an integrated knowledge translation approach with key knowledge users, the study’s findings have the potential to inform the optimization of integrated care, to positively impact the health of adults with complex needs, and reduce the economic burden to the health and social care systems.
Highlights
Adults with chronic conditions who suffer from mental health comorbidities and/or social vul‐ nerability require services from many providers across different sectors
Research objectives The objectives of the study are to: 1) identify individual and environmental characteristics of patients with complex needs that are associated with good or poor experiences of care transitions; 2) better understand the care transition experience of patients with complex needs and their families across community, primary care, and hospital settings; 3) better understand the experience of providers and health managers regarding care transitions of patients with complex needs; 4) examine care transitions by bringing together the experiences of patients and family members, providers, and community partners, as well as health managers
The Patient Experience of Integrated Care Scale (12 items) [68], which we developed and validated from a set of items proposed by the Picker Institute Europe and the University of Oxford [69], will allow us to focus on the global experience of care transitions
Summary
Adults with chronic conditions who suffer from mental health comorbidities and/or social vul‐ nerability require services from many providers across different sectors They may have complex health and social care needs and experience poorer health indicators and high mortality rates while generating considerable costs to the health and social services system. Nearly 70% of healthcare costs [4] are attributable to 10% of the population, mainly because of complex needs [5, 6] Services organization for these adults with complex needs requires integrated care across providers of all settings and sectors [7, 8]. Better understanding of care transitions of adults with complex needs is necessary mandatory to improve and implement these models of integrated care [13]
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