Transforming Health with Integrated Care: Research Profiles

Network for Integrated Care Excellence (NICE) Canada

Research summary: The CIHR THINC initiative has funded upwards of 100 grants to address the complex challenges associated with implementing and sustaining integrated care at scale. The Network for Integrated Care Excellence (NICE) Canada will tie together these multiple projects into a coherent approach and to ensure that the new knowledge is amplified and impacts on the delivery of care across Canada.

Principal Investigator(s) / Researchers:

• Researcher: Walter Wodchis (Nominated Principal Applicant, Scientific Lead, Impact Lead)
• Decision-maker: Jodeme Goldhar (Knowledge Brokering and Mobilization Lead)

Knowledge Mobilization and Impact Champion:

• Richard Lewanczuk, Principal Knowledge User & System Champion
• Sharon Anderson, Community Co-Champion
• Maureen Smith, Community Co-Champion
• Jennifer Walker, Indigenous Health Research Co-Champion
• Chelsea Gabel, Indigenous Health Research Co-Champion
• Amity Quinn, Sex/Gender Champion
• Paul Wankah, EDI Champion

Contact information: Walter.Wodchis@utoronto.ca, Jodeme@me.com

Twitter: @wwodchis, @JodemeGoldhar

Funders: The CIHR Institute of Health Services and Policy Research (IHSPR) and the CIHR HIV/AIDS and STBBI Research Initiative.

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Digitizing Integrated Care – Aligning technology to values

Name(s): Dr. Carolyn Steele Gray, Dr. Jennifer Major, Dr. James Shaw

Location (city, province): Toronto, ON

Program: Catalyst Grant: Quadruple Aim and Equity

Implementing and evaluating the ELEVATE innovation: an IntegratEd health care innovation to engage older patienTs and families within their home and community

Name(s): Dr. Joan Tranmer, Dr. Kimberley Morrison

Location (city, province): Kingston, ON

Program: Catalyst Grant: Quadruple Aim and Equity

Co-creating recommendations for strengthening coordinated intersectoral health promotion in British Columbia: Starting with physical activity

Name(s): Dr. Lori Baugh Littlejohns

Location (city, province): Vancouver and Invermere, BC

Program: 2021 Health System Impact Fellow

An examination of how to design primary health care networks using a patient-centred, needs-based approach

Name(s): Mike Reid

Location (city, province): Halifax, NS

Program: 2021 Health System Impact Fellow

Identifying service gaps between primary and speciaty care for patients with rheumatoid arthritis

Name(s): Dr. Xiaoxiao Liu

Location (city, province): Calgary, AB

Program: 2021 Health System Impact Fellow

No quality without equity in the care of older adults with complex health issues

Name(s): Dr. Amina Jabbar

Location (city, province): Mississauga, ON

Program: 2021 Health System Impact Fellow

Developing a Sustainable and Evidence-Based Integrated Model of Care for Pain Management in Alberta

Name(s): Dr. Elena Lopatina

Location (city, province): Calgary, AB

Program: 2021 Health System Impact Fellow

Using Digital Health to Better Serve Rural Albertans living with Shoulder Pathology: Alberta's Remote Management of ShoUlders Program (ARMS UP)

Research summary: Rural patients with shoulder pain have limited access to healthcare. Shoulder Rapid Assessment Clinics(RACs) reduce wait-times and improve outcomes; 25-45% of RAC patients are rural. ARMS UP will integrate 2 urban RACs (EDecision-makeronton, Lethbridge) with 8 rural TeleRehab sites to provide specialist care closer to home, improving patient health and experience (convenience/cost) and providers’ work-life to promote rural health equity.

Principal Investigators:

• Researchers: Lauren Beaupre (Researcher; Nominated Principal Investigator), Breda Eubank, Martin Ferguson-Pell
• Decision-maker: Elaine Finseth
• Provider: David Sheps
• Patient with Lived Experience: Landon Charlton

Knowledge Mobilization and Impact Champion:

• Ania Kania-Richmond
• Jason Martyn

Contact information: Lauren.beaupre@ualberta.ca

Funders: CIHR - Institute of Health Services and Policy Research (IHSPR), Strategy for Patient-Oriented Research (SPOR) and Institute of Musculoskeletal Health and Arthritis (IMHA)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

SPIRO: SPirometry for Improved Indigenous and Rural Respiratory Outcomes

Research summary: A spirometry test is used to diagnose chronic obstructive pulmonary disease (COPD). Most people don’t have access to spirometry, especially those in remote, rural, and Indigenous communities. There are many complex, multi-system barriers to increasing access to spirometry. The vision for the SPIRO team is to enhance spirometry and respiratory services and ultimately improve the health of people with COPD.

Principal Investigators:

• Researchers: Pat Camp (Nominated Principal Applicant and Researcher), Brittany Bingham, Lindsay Hedden, Samir Gupta, Kate Johnson
• Person with Lived Experience: Lisa Gordon
• Decision-Makers: Julia Pemberton, Lisette Vienneau, Travis Holyk, Vivian Eliopolous
• Providers: Sharla Rae Olsen, Ron Mundy, Breanne Abbott, John Pawlovich

Knowledge Mobilization and Impact Champion:

• Samir Gupta
• Pat Camp

Contact information: Pat.camp@hli.ubc.ca

Twitter: @UBCPulmRehabRes

Funders: CIHR - Institute of Health Services and Policy Research (IHSPR) and Strategy for Patient-Oriented Research (SPOR)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

ThiiNC-ECHO: Testing Healthcare innovations in integrated Networks for Chronic Pain: Evaluation of the Implementation of ECHO Chronic Pain in Canada

Research summary: Chronic pain affects 20% of the population. In 2014, ECHO was implemented in Canada as a platform for rapid knowledge dissemination of best practices, clinical practice guidelines, and community resources using a hub-and-spoke model. Using implementation science methods and knowledge mobilization approaches, this research will guide, measure and support the successful spread and scale of ECHO chronic pain in Canada.

Principal Investigators:

• Researcher: Dr. Andrea Furlan (Nominated Principal Investigator)
• Decision Maker: Jean-Francois Leroux
• Person with Lived Experience: Helena Daudt
• Provider: Dr. Lori Montgomery

Knowledge Mobilization and Impact Champion

• Dr. Katie Birnie

Contact information: andrea.furlan@uhn.ca

Twitter: @adfurlan

Funders: CIHR - Institute of Musculoskeletal Health and Arthritis (IMHA), Strategy for Patient-Oriented Research (SPOR), and Saskatchewan Health Research Foundation (SHRF)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Integrated Care Clinical Pathway Implementation using a Patient Oriented Learning Health System Approach: A Realist Process Evaluation of the Saskatchewan Long COVID Pathway

Research summary: A Long COVID (LC) clinical pathway (CPW), established by the Saskatchewan Health Authority (SHA), aims to improve care for patients suffering with LC. By taking a realist research approach, our team of patient partners, researchers, health care providers, and health system leaders can provide our SHA with evidence to understand what makes a successful, economically efficient, and sustainable LC CPW.

Principal Investigators:

• Researchers: Dr. Gary Groot (Nominated Principal Investigator), Dr. Tracey Carr, Dr. Donna Goodridge (Sex and Gender Champion), Dr. Erika Penz
• Decision-makers: Collin Hartness, Patricia Comfort
• Providers: Dr. Andrea Vasquez-Camargo (Equity-Diversity-Inclusion champion), Dr. Mark Fenton
• Person with Lived Experience/Patient Partner: Brenda Andreas, Jennifer Lessard, Allan O’byrne

Knowledge Mobilization and Impact Champion:

• Dr. Nazeem Muhajarine (researcher)

Contact information: gary.groot@usask.ca

Twitter: @Groot_Research

Funders: CIHR - Institute of Health Services and Policy Research (IHSPR), Institute of Circulatory and Respiratory Health (ICRH), Strategy for Patient-Oriented Research (SPOR) and Saskatchewan Health Research Foundation (SHRF)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

PriCARE Integration – Case management in primary healthcare for people with complex healthcare needs to improve integrated care: a large-scale implementation study

Resesarch Summary: To inform the implementation of case management (CM) intervention on a larger scale across similar and different health system contexts, the aim is to scale up CM in primary healthcare for people with complex needs and generate new evidence to inform policies and healthcare system transformation towards more integrated care, to positively impact many Canadians on the quintuple aim.

Principal Investigator(s):

• Researchers: Catherine Hudon (Nominated Principal Investigator), Maud-Christine Chouinard, Shelley Doucet, Helena Piccinini-Vallis.
• Decision-makers: Kimberly Fairman, Philippe Lachance, Tara Sampalli, Greg Sargent.
• Persons with lived/living experience: René Benoît, André Gaudreau, Audrey-Lise Rock-Hervieux, Donna Rubenstein, Linda Wilhelm.
• Provider: Joanna Zed

Knowledge Mobilization and Impact Champion:

• Catherine Hudon

Contact information: catherine.hudon@usherbrooke.ca

Twitter: @V1SAGES

Funders: CIHR - Strategy for Patient-Oriented Research (SPOR), Institute of Musculoskeletal Health and Arthritis (IMHA), Fonds de recherche du Québec – Santé (FRQS), and ResearchNB

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Improving sexual health for Canadians through a pharmacy-based sexual health services model

Research summary: Access to testing, treatment and prevention services for sexually transmitted/bloodborne infections is challenging for many Canadians. Offering these services through pharmacies improves access and equity, is desired by clients, and cost-effective to find and prevent infections. Through this project we will work with stakeholders to assess readiness and support integration of PbSHS into healthcare systems in Atlantic Canada and Alberta.

Principal Investigator(s):

• Researchers: Deborah Kelly (Nominated Principal Investigator), Kyle Wilby
• Decision-makers: Jenni Godsell, Paula McNeil, Dylan Moulton, Greg Richard
• Providers: Peter Daley, Todd Hatchette, Brian Moore
• Person with lived experience: Deborah Norris, Rheya White

Knowledge Mobilization and Impact Champion:

• Deborah Kelly

Contact information: dvkelly@mun.ca

Twitter: @DebbieVKelly

Funders: CIHR - HIV/AIDS and STBBI Research Initiative and Strategy for Patient-Oriented Research (SPOR)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Avoiding Diabetes After Pregnancy Together with Moms (ADAPT-M): Bridging Care from the Third to the Fourth Trimester

Research summary: ADAPT-M is a virtual health coaching program that bridges prenatal and postpartum care for women with gestational diabetes, to help them prevent future type 2 diabetes. A trial of ADAPT-M has been completed, and we will design a strategy for implementation in 3 Ontario regions. ADAPT-M will reduce diabetes burden by transforming care and improving health for this high-risk population.

Principal Investigator(s):

• Researcher: Lorraine Lipscombe (Nominated Principal Investigator), Diana Sherifali
• Decision-Maker: Sacha Bhatia, Jennifer Strome, Ann Philips, Janet Macleod
• Person with Lived Experience: Sadia Mian
• Provider: Sandra Fitzpatrick, Karen Fleming

Knowledge Mobilization and Impact Champion:

• Monika Kastner

Contact information: Lorraine.lipscombe@wchospital.ca

Twitter: @LorraineLipsc17

Funders: CIHR - Institute of Health Services and Policy Research (IHSPR), Strategy for Patient-Oriented Research (SPOR), Institute of Musculoskeletal Health and Arthritis (IMHA), and Ontario Ministry of Health

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Tackling Eating Disorders early: Enhancing a new model for early intervention of Eating Disorders in Ontario through Integrated Youth Services

Research summary: Building off investments made by the Ontario government in testing an early intervention model to address Eating Disorders through Youth Wellness Hubs Ontario, we will partner with youth, family members, clinicians, researchers and others to synthesize, mobilize and adapt the First Episode Rapid Early Intervention for Eating Disorders (FREED) model for Integrated Youth Services throughout Canada.

Principal Investigator(s):

• Researcher: Dr. Nicole Obeid (Nominated Principal Investigator)
• Decision-maker: Dr. Jo Henderson
• Provider: Dr. Gina Dimitropoulos
• Person with lived/living experience: Emily Beaton, Hilary Allen

Knowledge Mobilization and Impact Champion:

• Dr. Purnima Sundar – Executive Director, Knowledge Institute for Child and Youth Mental Health

Contact information: nobeid@cheo.on.ca

Twitter: @CHEO, #CHEOResearch

Funders: CIHR - Institute of Health Services and Policy Research (IHSPR), Strategy for Patient-Oriented Research (SPOR), and Institute of Musculoskeletal Health and Arthritis (IMHA)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Project ECHO Autism Diagnosis and Integrated care Opportunities: ECHO AuDIO

Research summary: Autistic children and youth struggle to access timely autism diagnosis and ongoing integrated care. Project ECHO Autism is an evidence-based intervention for community health care providers to enhance their autism care. Project ECHO Autism Diagnosis and Integrated care Opportunities (ECHO AuDIO) will implement these critical elements in ECHO Autism programs across Canada, providing children with timely, integrated, community-based care.

Principal Investigators:

• Researchers: Melanie Penner (Nominated Principal Investigator), Meng-Chuan Lai (Sex and Gender Champion), Sachindri Wijekoon (Equity, Diversity and Inclusion Champion)
• Decision Maker: Paula Robeson (Children’s Healthcare Canada)
• Provider: Anamaria Richardson (Equity-Diversity-Inclusion champsion)
• Persons with lived/living experience: Maddy Dever (advocate & parent); Munira Khilji (parent)

Knowledge Mobilization and Impact Champion:

• Rachel Flynn (researcher)

Contact information: mpenner@hollandbloorview.ca

Twitter: @drmelpenner

Funders: CIHR - Institute of Human Development, Child and Youth Health (IHDCYH), and Strategy for Patient-Oriented Research (SPOR)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

The Ontario Rheumatology Learning Health System for Transforming Integrated Care for Patients with Rheumatic & MSK Disorders

Research summary: Our team will develop a rheumatology learning health system to accelerate models of care evaluation, equity-focused quality improvement evaluations, and knowledge exchange of evidence-based practices in real-world clinical settings to generate actionable evidence to improve integrated care for individuals with rheumatic and musculoskeletal disorders, which will improve equity and patient outcomes, population health and support a more sustainable rheumatology workforce.

Principal Investigators:

• Researchers: Jessica Widdifield, Celia Laur, Lihi Eder
• Provider: Carter Thorne, Vandana Ahluwalia
• Decision-maker: Tom Appleton (Ontario Rheumatology Association)
• Persons with lived/living experience: Catherine Hofstetter

Knowledge Mobilization and Impact Champion:

• Vandana Ahluwalia

Contact information: Jessica.widdifield@utoronto.ca, Celia.Laur@wchospital.ca

Twitter: @Celia_Laur, @lihi_eder, @ORAexec

Funders: CIHR - Institute of Musculoskeletal Health and Arthritis (IMHA) and Strategy for Patient-Oriented Research (SPOR)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Implementation and Impacts of the Quebec Action Plan for Chronic Pain

Research summary: In 2021, the Quebec Health Ministry launched its Action Plan for Chronic Pain in order to significantly improve the access and quality of health services offered to people who experience chronic pain. The primary objective of this project, which uses a mixed method design, is to evaluate implementation processes and impacts of the Action Plan’s first phase.

Principal Investigators:

• Researchers: Gabrielle Pagé, Yves Couturier
• Decision-maker: Nathalie Labrecque
• Provider: Aline Boulanger, Isabelle Gaumond
• Persons with lived/living experience: Dominique Chaussé, Jacques Laliberté

Knowledge Mobilization and Impact Champion:

• Gabrielle Pagé
• Anne-Marie Pinard

Contact information: gabrielle.page@umontreal.ca

Funders: CIHR-Strategy for Patient-Oriented Research (SPOR) and Fonds de recherche du Québec – Santé (FRQS)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Paving a Road Map for Integrated Care Evaluation in Canada: A Mixed Methods Evaluation for Patients with Complex Care Needs in Ontario and Alberta

Research summary: Our project refines and spreads an existing integrated health and social care pathway to hospitalized patients with complex care needs in Toronto, Ontario and Calgary, Alberta. Our research will create an evaluation pathway grounded in high quality patient experience during care transitions from hospital, support aging in place for vulnerable older adults and reduce the demand on acute care.

Principal Investigators:

• Researchers: Dr. Karen Okrainec (Nominated Principal Investigator), Dr. Michelle Grinman
• Provider: Dr. Tom Macmillan
• Decision-maker: Shiran Isaacksz
• Persons with lived/living experience: Phyllis Berck

Knowledge Mobilization and Impact Champion:

• Dr. Michelle Grinman (Researcher)

Contact information: Karen.Okrainec@uhn.ca

Twitter: @drkokrainec

Funders: CIHR - Institute of Aging, Strategy for Patient-Oriented Research (SPOR), Institute of Circulatory and Respiratory Health (ICRH), and Ontario Ministry of Health

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)

Adapting Walk the Talk Toolkit for Equity Deserving Groups: A Pan-Canadian Study

Research summary: The aim of this study is to socially and culturally adapt Walk the Talk Toolkit for equity deserving groups across Canada. Walk the Talk Toolkit is an online bilingual toolkit designed to help organizations implement the Canadian Guidelines for Recovery-Oriented Practice. These Guidelines, published by the Mental Health Commission of Canada, do not provide a process that organizations can use to implement these guidelines. Walk the Talk Toolkit is a pragmatic implementation science-based approach to promote uptake and sustainability of recovery-oriented integrated care in Canada and a bridge between psychiatric and community-based services. Our focus is on adapting Walk the Talk Toolkit for organizations serving marginalized populations, including groups who are marginalized on the basis of their gender, heritage, nationality, race or ethnicity

Principal Investigator(s) / Researchers:

• Researchers: Myra Piat (Nominated Principal Investigator), Marie-Pier Rivest, Ian Graham, Helene Albert, Shannon Wiltsey-Sirman, Michel Perreault, Geneveive Sauvé, Lena Palaniyappan
• Decision-maker: Maura Lawless, Bonnie McCloud, Linda O’Brien, Sonia Côté, Ina Winkelmann, Gael Gilbert
• Persons with lived/living experience: Carol Plathan, Dawn Baker, Ernest Guptil
• Provider: Katelyn Feather, Martha Singh Jennings, Mireille Couture, Francois Hubin, Anita Makokis, Ali Serjeant, Jennifer Moutinho

Knowledge Mobilization and Impact Champion:

• Myra Piat
• Ian Graham

The Leadership Team includes 27 Knowledge Users and 8 researchers including: 6 Principal Knowledge Users (CEOs) and 20 other Knowledge Users from each site: service users, family members, service providers and policy makers.

Contact information: myra.piat@douglas.mcgill.ca

Twitter: @MyraPiat

Funders: CIHR-Strategy for Patient-Oriented Research (SPOR) and Social Sciences and Humanities Research Council (SSHRC)

Program: Transforming Health with Integrated Care (THINC) – Implementation Science Team (IST)