Building the Evidence: Caring for Complex Patients in Ontario

November 20, 2014

By Dr. Reva Adler

In 2011, Dr. Terri Fried at Yale University conducted focus groups with 40 primary care practitioners regarding their approach to treatment decision-making for persons with more than one chronic illness.  Reporting their findings in the Archives of Internal Medicine, Dr. Fried's team concluded that practicing physicians "struggle with the uncertainties of applying disease-specific guidelines to patients with multiple conditions."

The contemporary Canadian health system was not designed to understand, let alone focus on, the increasing population of individuals with complex, chronic health conditions. To illustrate the impact of chronic diseases in Ontario, in 2003 it was estimated that approximately 50% of persons over the age of 45 were living with more than one chronic condition. This is due to the fact that if left untreated, a single serious chronic condition will result in additional health problems. For example, in the same population, 43% of heart failures, 30% of strokes, 51% of new dialysis starts, and 70% of amputations occurred in persons with pre-existing diabetes mellitus. 

As healthcare moves into the world of "evidence-informed," guideline-based care, these critical questions arise: What is best practice when working with individuals living with multiple health conditions? What are the goals of care for these individuals? What outcomes do patients seek? What evidence is available to guide us?

There is little, if any, high-quality evidence available to guide healthcare decision-making for the growing group of Canadians living with more than one interacting, chronic health condition. Bridgepoint is taking the lead in propelling this critical agenda forward.

To address health complexity in all of its domains, we need to ask the following questions with each of our patients:

How well are you?

How are you coping with your health issues?

How happy are you with our day to day circumstances?

Do you feel you make a difference in the world around you?

Are you able to access the day-to-day health services you need?

In pursuing a unique answer to each of these questions, Bridgepoint developed a new model of inpatient care based on the IMPACT (Interprofessional Model of Practice for Aging and Complex Treatment) model of primary care.  IMPACT works to "unpack" and prioritize the full array of patients' health issues and concerns, and to develop a comprehensive "whole person" plan that targets the highest priority issues. 

Toward this end, Bridgepoint has received funding to develop and evaluate the efficacy of different versions of the IMPACT model in three novel settings:  on our inpatient medical rehabilitation units, within a consultation team working throughout the hospital, and in our ambulatory care centre. This research will not only test the ability of IMPACT to achieve key patient-identified outcomes, but will also investigate the best protocols to be used to treat single and grouped problems when they exist in a context of multiple, coexisting health conditions. 

Through a unified program of clinical care and research seeking to identify the best care practices, Bridgepoint is working continuously to generate, disseminate and translate new knowledge focused on improving the health of all Ontarians and help Ontario lead the development of evidence-based care for complex patients.

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