Many readmissions to hospital can be prevented with appropriate primary care and community supports. Interventions to address care gaps during these transitions in care have tended to be disease-specific (e.g., heart failure, cancer) and have been developed in hospitals by specialists; 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.

This project will establish a common platform to integrate primary care and specialist led transitions in care pathways in order to scale and spread the current disease-specific pathways work across Alberta for patients with chronic medical diseases.

The aim is to  strengthen the hospital admission and discharge planning processes and follow-up to primary care for patients with the following chronic conditions: heart failure, chronic obstructive pulmonary disease, cirrhosis, end-stage kidney disease and/or stage 3-4 cancers.

Learn more about the pathway here.

This project is funded by Alberta Innovates – Partnership for Research and Innovation in the Health System (PRIHS).

To attain quality patient outcomes and optimize system performance there needs to be an integrated approach to care. Integrated care is a multi-level, demand-driven and person-centered strategy designed to address complex and costly health needs by better coordinating services across the care continuum. The use of clinical pathways has been shown to be effective in integrating care, increasing uptake of evidence-based practice, and optimizing patient outcomes.

This project will work with community and primary care to adapt, scale, and extend the Conservative Kidney Management Pathway to other areas of chronic illness.  The aim is to implement and evaluate an innovative Supportive Care Pathway for Albertans with advanced organ failure and metastatic cancer, who are unlikely to benefit from curative or life-prolonging treatments.

Learn more about the pathway here.

This project is funded by the Canadian Institute of Health Research – SPOR iCT Rewarding Success Operating Grant.

The CKM pathway has been developed for patients with end stage kidney failure unlikely to benefit from chronic dialysis and who choose conservative (non-dialysis) care. These patients may live as long as those who decide to start dialysis, while still maintaining a better quality of life.

The pathway coordinates kidney care with relevant primary and palliative care services, and will incorporate new initiatives currently being developed and rolled out under the direction of Alberta Health Services. It is anticipated that the CKM pathway will reduce the burden on acute care facilities as well as enable quality, efficient, cost-effective and standardized CKM care, regardless of location. The  CKM pathway will also enable greater control for patients and their families to make decisions regarding dialysis or CKM consistent with their values and goals. Comprehensive evaluation is ongoing.

Learn more about the pathway here.

This project was funded by Alberta Innovates – Partnership for Research and Innovation in the Health System (PRIHS).

Patient decision aids (PDAs) provide a structured, evidence-based platform for staff to engage patients in these difficult conversations. PDAs have also have been shown to improve patient’s knowledge regarding treatment options, reduce their decisional conflict related to feeling uninformed and unclear about their personal values, enables them to take a more active role in decision-making and improves congruence between the chosen option and their values. PDAs are particularly beneficial when each option has benefits and harms that patients may value differently.

Information from the CKM pathway aided in the development and implementation an interactive, web-based PDA around the appropriate initiation of dialysis versus CKM based on the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. Comprehensive evaluation is ongoing.

This project was funded by Alberta Innovates – Partnership for Research and Innovation in the Health System (PRIHS).

This project will establish a common platform to integrate primary care and specialist led transitions in care pathways in order to scale and spread the current disease-specific pathways work across Alberta for patients with chronic medical diseases.

The aim is to  strengthen the hospital admission and discharge planning processes and follow-up to primary care for patients with the following chronic conditions: heart failure, chronic obstructive pulmonary disease, cirrhosis, end-stage kidney disease and/or stage 3-4 cancers.

Learn more about the pathway here.

This project is funded by Alberta Innovates – Partnership for Research and Innovation in the Health System (PRIHS).

This project will work with community and primary care to adapt, scale, and extend the Conservative Kidney Management Pathway to other areas of chronic illness.  The aim is to implement and evaluate an innovative Supportive Care Pathway for Albertans with advanced organ failure and metastatic cancer, who are unlikely to benefit from curative or life-prolonging treatments.

Learn more about the pathway here.

This project is funded by the Canadian Institute of Health Research – SPOR iCT Rewarding Success Operating Grant.

Patient decision aids (PDAs) provide a structured, evidence-based platform for staff to engage patients in these difficult conversations. PDAs have also have been shown to improve patient’s knowledge regarding treatment options, reduce their decisional conflict related to feeling uninformed and unclear about their personal values, enables them to take a more active role in decision-making and improves congruence between the chosen option and their values. PDAs are particularly beneficial when each option has benefits and harms that patients may value differently.

This project will establish a common platform to integrate primary care and specialist led transitions in care pathways in order to scale and spread the current disease-specific pathways work across Alberta for patients with chronic medical diseases.

The aim is to  strengthen the hospital admission and discharge planning processes and follow-up to primary care for patients with the following chronic conditions: heart failure, chronic obstructive pulmonary disease, cirrhosis, end-stage kidney disease and/or stage 3-4 cancers.

This project will work with community and primary care to adapt, scale, and extend the Conservative Kidney Management Pathway to other areas of chronic illness.  The aim is to implement and evaluate an innovative Supportive Care Pathway for Albertans with advanced organ failure and metastatic cancer, who are unlikely to benefit from curative or life-prolonging treatments.

Learn more about the pathway here.

This project is funded by the Canadian Institute of Health Research – SPOR iCT Rewarding Success Operating Grant.

The aims of this project are to work with Primary Care Networks to enhance and spread the implementation of an innovative CKM Pathway to community care across Alberta to improve patient outcomes for CKD patients unlikely to benefit from dialysis while providing better value for money. This work will operationalize innovative care creating sustainable transformation, set a benchmark for national and international jurisdictions, and will serve as a model for pathway development and integrated care for other vulnerable people with complex chronic illness.