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A DiseAse-inclusive Pathway for Transitions in Care (ADAPT)
Alberta Collaborative Pathway for Patients with Complex Chronic Diseases
Patients who have complex, chronic diseases often have extensive unmet care needs as they transition between hospital and home and regularly return to hospital due to a flare-up or progression of their medical condition. Many readmissions to hospital can be prevented with appropriate primary care and community supports. Most interventions to address gaps in care during transitions have been developed in hospitals by specialists and tend to be disease-specific without addressing multimorbidity. As a result, they are not necessarily optimized for family doctors who may not have the tools and resources to support the shared care needed by these patients.
In 2020 Dr. Sara Davison, in partnership with the Primary Health Care Integration Network, was awarded a 2.5 year, $1.2 million Alberta Innovates Partnership for Research Innovation in the Health System (PRIHS 5) grant to establish a common platform for transitions in care for Albertans with heart failure, chronic obstructive pulmonary disease, cirrhosis, end-stage kidney disease and/or stage 3-4 cancers.
To improve transitions in care, change must occur at the front-line in both acute and primary care settings. The engagement of key stakeholders and end-users is essential to support front-line staff and ensure their capacity to co-design and implement change to optimize the transition from hospital to home. This will ultimately reduce duplication of resources, increase efficiencies and promote the uptake and sustainability of the Transitions Guideline. ADAPT will engage patients and their families, Primary Care Networks, community physicians, Strategic Clinical Networks, community services, and acute care to co-design and implement elements of the H2H2H Transitions Guideline in five sites across Alberta.
To learn more about ADAPT please visit the Primary Health Care Integration Network webpage.
The Benefits of ADAPT
What Does this Study Offer Albertans?
Primary Care Physicians & Team Members?
Hospital Physicians & Team Members?
- Integrated approaches for home to hospital to home transitions,
- Improved patient and provider experiences,
- Enhanced community care
- Care that aligns with patient preferences, and
- Increased health systems efficiency.
- Standardized transition in care processes for patients with chronic conditions,
- Structured processes for timely and comprehensive transition planning,
- Change management and evaluation support, and
- Enhanced community capacity by empowering family physicians and supporting the patient's medical home.
- Change management and evaluation support,
- Supported shared care planning across providers, health teams and the care continuum,
- Supported transitions for high-risk patients from hospital to primary care, and
- Ongoing analytics support at a provincial, zonal & site level.
Alignment with other Provincial Initiatives
In 2020, Alberta launched the provincial H2H2H Transitions Guideline on how patients can best transition from their communities, to the hospital and back home again. The guideline includes six key elements: confirmation of the primary care provider, admit notification, transition planning, referrals and access to community supports, transition care plan and follow-up to primary care.
ADAPT will support the implementation of three of the six H2H2H Guideline elements (admit notification, transition planning, and follow-up to primary care) in acute care and primary care settings. The two initiatives share similar expect outcomes such as reduced readmission rate, however, ADAPT concentrates on transitions in care for patients with complex chronic conditions while H2H2H focuses on transitions for all adult Albertans. Together the two initiatives will collaboratively engage and consult with key stakeholders and partners.
One:carepath is an Integrated Supportive Care Pathway that takes a proactive and co-managed approach in shared-care planning with patients who have advanced-stage (non-curative) lung, heart, liver and kidney disease and/or cancers. This provincial initiative aims to provide symptom and crisis management, help patients maintain quality of life and functional status, avoid aggressive treatments, where appropriate, and align care with patient preferences and values.
Although ADAPT and one:carepath are working towards improving the same key outcomes (care planning and patient outcomes) for patients with complex chronic conditions, the two initiatives focus on discrete aspects of the patient' journey through the healthcare system. While ADAPT focuses on patient transitions from hospital to home, one:carepath aims to keep patients in their medical home after they have transitioned out of hospital. Together the initiatives are leading a coordinated approach to integrate, spread, and scale current disease-specific pathways work into a disease-inclusive approach to be used in primary care.
Vision: To help people enjoy life while living with advanced chronic kidney disease by becoming a world leader in kidney supportive care research and clinical innovation.