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The Right Care, in the Right Place, at the Right Time, by the Right Health Team

What is One:carepath?

One:carepath is a patient-first, disease-inclusive approach to integrating supportive care within primary care for patients with advanced/decompensated/non-curative COPD, heart failure, cirrhosis, kidney disease or stage 3 or 4 solid organ cancers. This provincial research project includes a co-designed shared care plan template and online digital support tool focusing on optimizing a patient’s quality of life and functional status through careful attention to symptom management, avoiding aggressive treatments where appropriate, and determining a patient’s values and preferences for care. All with the goal to increase informational, relational, and management continuity among all those involved, and reduce hospital admissions and emergency department visits.

Although this research project is focusing on some specific disease processes, the provincial long-term goal is to support any patient who can benefit from supportive care.

This project is lead by Dr. Sara Davison, Dr. Brad Bahler and Dr. Charlie Chen, and will work with primary care and community providers to adapt, scale, and extend the Conservative Kidney Management Pathway to other areas of chronic illness.

This study is funded by the Canadian Institute of Health Research, Alberta Health Services and Alberta Innovates – Strategy for Patient-Oriented Research (SPOR) innovative Clinical Trials (iCT) Rewarding Success Team Grant.

What Will One:carepath Provide?

A patient-centered Shared Care Plan template for patients with complex health needs, that allows for iterative and dynamic changes as the patient navigates the health system to support:

  • Patients and their families at every point in their health care journey, regardless of where they touch the health system;
  • Providers, including allied health providers, at every interaction, ensuring health information is transparent, secure and available to enhance and augment clinical decisions, and;
  • Alberta’s Health System by connecting and coordinating multidisciplinary teams who work together across settings and use evidence to strengthen patient-centered interactions.

A website, with parallel arms for healthcare providers & patients/families that includes a suite of tools and resources leveraging disease specific Alberta Health Services pathways content (where appropriate), accessible for use in primary care, and tailored to the complex patient to support them in their medical home. The content is focused predominantly on:

  • Communication around patient preferences and values, and the development of an aligned patient-centered care plan;
  • Symptom management, and;
  • Managing advanced disease complications that add to symptom burden; this may include interventions to slow progression of disease.

For more information about about the initiative or how to get involved please contact Tanya Barber at tkbarber@ualberta.ca or Lynn Toon at toon@ualberta.ca.

Explore one:carepath

The digital support tools and resources are publicly available to patients, families and healthcare practitioners at: onecarepath.ahs.ca

The Benefits of One:carepath

For Patients:

For Primary Care Health Teams:

  • Enhance community-based care across Alberta, supporting patients with advanced stage chronic diseases who are unlikely to benefit from aggressive treatments;
  • Help provide patients with the right care, in the right place, at the right time, by the right health team. Facilitating integrated approaches to home and community-based care, including rural/remote communities across Alberta;
  • Support patients who choose a conservative approach to manage their chronic condition, and;
  • Reduce resource use/cost across the health system and improve patient outcomes.
  • An opportunity to support the development and implementation of process and workflows for care planning by leveraging clinic EMRs and available PCN resources/project tools;
  • Develop proactive, effective, efficient, patient centered and evidence-based approaches to care planning;
  • Build relationships between primary care, specialists and specialty programs for enhanced integration, and continuity of care for patients, and;
  • Advance the development of the patient’s medical home by improving care coordination.

Shared Care Planning in the Medical Home

It is generally accepted that the next step of advancing the Patient Medical Home (PMH) is transparent care planning when good work has been done in:

  • Engaged Leadership: identifying leaders who support the PMH and removed barriers while reinforcing key messages,
  • Capacity for Improvement: building quality improvement muscle and Panel management, and
  • Team Based Care: building your team and moving toward a shared approach to patient care.

One:carepath aims to provide tools for health care teams that support shared care planning and care coordination for patients in their medical home.

One:carepath will provide ongoing support to care providers and patients to implement a shared care plan that addresses: 1) patient's preference for care, 2) consideration of multiple health conditions, 3) progression of disease, 4) symptom management, and 5) crisis planning and end-of-life care.

Additional Resources

General Overview

A brief summary of the one:carepath initiative

Key Messages

Information for primary care physicians

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.

Kidney Supportive Care Research Group (KSCRG)  l  Mailing Address: 8-105 Clinical Sciences Building, University of Alberta, 11350 83 Avenue NW, Edmonton, AB, T6G 2G3  l  Email: kscrg@ualberta.ca  l  Phone: (780) 492-0926 l  Fax: (780) 407-8117