Chronic diseases account for $93 billion annually in Canada to manage. Despite this spending, 12% of Canadians report being unsatisfied with healthcare quality, posing a challenge for policymakers. The document proposes several projects to identify effective interventions for improving primary care practices and outcomes for patients with chronic conditions. It will analyze policies across Canadian provinces to better integrate health, social, and community services and identify best practices. It will also evaluate tools to screen for social determinants of health and characterize high healthcare users.

1. M A N I T O B A P R I M A R Y A N D I N T E G R A T E D
H E A L T H C A R E I N N O V A T I O N N E T W O R K
PROJECTS

2. KNOWLEDGE SYNTHESIS
Approximately six in ten Canadians aged 20 years and older live with chronic diseases
and account for $93 billion/year to manage chronic diseases. Despite the enormous
expenditure, 12% of Canadians have reported feeling unsatisfied with the quality of care, which
pose a major challenge for Canadian primary health care policy makers. To close the quality
gap, Quebec, Ontario and Alberta have implemented a "patient-centered medical home" model,
while Manitoba is following the suit. However, it is unclear which interventions and policies are
appropriate, sustainable and sufficient to fill the perceived quality gap by influencing primary
care professionals' practice change.
The objectives of this policy-makers' need-driven evidence synthesis are to: 1) identify,
classify and critically appraise interventions and policies influencing primary healthcare
professionals; 2) determine their efficacy and feasibility in the primary care settings primarily
managing chronic diseases; 3) assess factors affecting response level; 4) provide evidence-
based recommendations to policy-makers in the Canadian context; and 5) identify knowledge
gaps for future research.
Methodology: We will include reviews evaluating interventions or policies on primary healthcare
professionals' practice, primarily evaluated in developed countries, published as full-text articles
within the last decade. Following the standard evidence synthesis processes, we will judge the
direction and significance of the practice change in the context of patients' and professionals'
outcomes. The interdisciplinary team includes subject experts, knowledge users, primary
healthcare networks, patient representative, and partners.
Potential outcomes: This evidence synthesis will identify effective interventions and policies
influencing primary care providers' practice in the Canadian context. Our evidence-based
recommendations to policy-makers will be used to achieve objectives of patient-centered
medical homes in Canada.
Interventions and Policies Influencing Primary Healthcare Professionals
Managing Chronic Diseases: An Evidence Synthesis
Manitoba Researchers: Bhupendrasinh Chauhan (NPI), Jeanette Edwards,
Ryan Zarychanski, Gayle Halas, Terry Klassen, Kathryn Sibley, Alexander Singer,
Beverley Temple

3. COMPARATIVE PROGRAM AND
POLICY ANALYSIS
Policies and program innovations that connect primary health
care, social services, public health and community supports in
Canada: A comparative policy analysis
Manitoba Researchers: Tara Stewart, Jeanette Edwards, Kristin Anderson, Arle
Jones, Colleen Metge, Nancy Newall
Children and youth and older adults with serious chronic conditions and with limited
or diminishing capacity to look after themselves independently often need their
primary care providers to connect them to social services, public health services and
community supports. These can be services such as home care, housekeeping, education
aids, income assistance, legal services and respite care. Failure to connect to needed
services leads to negative experiences for patients, caregivers and health professionals alike;
it also leads to poor health outcomes and health system inefficiencies.
The goal of this research is to help future development of models of care that connect
smoothly across health, social and community services. We will study the policies and
governing structures that restrict or allow connections in different provinces and territories.
Then we will identify examples of successful and unsuccessful programs that were designed
to connect services so we can learn from best practices and failures.
We specifically focus on what hinders information sharing across services, again looking for
examples of where information flow and linkage works.Better data linkage across multiple
services is good for patient care, but it will also help researchers who want to study what
happens to patients.
Results from the study will help various teams who are currently planning to design and
study these integrated service delivery models. We believe that the findings will also be
relevant to other populations with complex needs like people with mental health and
substance abuse issues.

4. QUICK STRIKES
Evaluating the implementation and impact of an online tool used within
primary care to improve the income security of patients with complex
health and social needs in Ontario and Manitoba
Manitoba Researchers: Alan Katz, Alex Singer, Gayle Halas, Katelin
McDermott and Kristin Anderson.
Social conditions such as a person’s income security, food security,
housing status and educational attainment impact the health of
individuals. These social determinants are relevant to caring for patients with
complex health and social needs.
This research will evaluate an online tool that works by prompting the health
provider at several primary care sites to screen for poverty, and if identified, to
recommend benefits or other financial resources, as well as local community
resources to assist with obtaining these benefits.
In addition to further developing a tool in collaboration with Ontario
researchers and advisory groups in both jurisdictions, the evaluation will
examine implementation feasibility and acceptability; identify challenges and
opportunities for its use and; gain user perspectives and outcomes related to
patient use.

5. QUICK STRIKES
Characterizing high system use across the primary-tertiary
care continuum: parallel analyses of select Canadian health
datasets
Manitoba Researchers: Alex Singer, Alan Katz and Gayle Halas.
A small number of users in the health care system
disproportionately consume a majority share of health care
resources. A better understanding of high system users may lead to
improved management of these patients, with a sizeable impact on
health care spending, quality of care and patient outcomes.
This study will leverage detailed and complementary data from
three distinct Canadian sources to improve our understanding of the
clinical, social, and demographic characteristics of high system
users across the health care continuum.
We will put specific emphasis on patients identified as being
medically and/or socially complex and determine how complexity is
distributed among high system users.

6. QUICK STRIKES
A Comparative Analysis of Centralized Waiting Lists for Unattached and
Complex Patients Implemented in Six Canadian Provinces
Manitoba Researchers: Sara Kreindler, Michelle Turnbull
Many Canadians do not have a regular family doctor. A lot of these people
are sick, poor, immigrant or alone and would really benefit from having a family
doctor. Not having a family doctor makes it harder to get the care they need and,
so, they go to the emergency more often and are less healthy. Six provinces have
put in place a system to help these people find a family doctor. Essentially, those
who do not have a family doctor can register on a provincial waiting list and,
eventually, be matched with a doctor. However, each of these systems works
differently and each province knows very little about how other provinces are
helping people find a family doctor.
This research project wants 1) to understand each province's system by talking
to those in charge of these systems, 2) to find the best ways of doing things by
talking to experts and looking at articles on the subject and 3) to share this
information with those involved in managing each province's system. Managers,
doctors and researchers from each province will meet to compare what they are
doing in their province to what other provinces are doing and to the best ways of
doing things according to experts to see where they could improve. The idea is
that each province will find strategies to help more people find a family doctor,
especially those who would benefit most from it.

7. QUICK STRIKES
Improving care and outcomes of patients with CKD managed in primary care
Manitoba Researchers: Navdeep Tangri, Alexander Singer
Chronic kidney disease (CKD) is a significant burden on patients and healthcare
systems, as it leads to kidney failure, requiring dialysis, and accelerated heart disease
and strokes. There is evidence that early identification and effective management of CKD
prevents its progression to kidney failure and also reduces risk of heart disease and strokes.
However, unlike with other chronic diseases, such as cancer and lung diseases, early
identification of CKD is a huge challenge due to absence of clinical symptoms until the
disease is really advanced, when interventions are not likely to be beneficial.
The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is a primary care
initiative, and the first Canada-wide multi-disease population health surveillance system
collecting health information from electronic medical records in the offices of participating
primary care providers (family doctors), in order to improve the way chronic diseases are
monitored and managed.
Data are extracted every three months, which allows for health patterns to be detected and
acted upon in a timely and efficient manner.
In partnership with the CPCSSN, we plan to develop an effective mechanism for early
detection and management of CKD in the community allowing for application of effective
treatments when there is the highest potential for impact. This will reduce the risk of
development of kidney failure requiring dialysis or transplant as well as heart disease and
strokes.
We will work with policymakers and patient groups to ensure an effective uptake of our
findings to impact positively the care of the teeming patients with CKD in our communities.

8. QUICK STRIKES
Validation of Administrative and Primary Care Electronic Medical Record
derived Frailty algorithms
Manitoba Researchers: Alan Katz, Jeanette Edwards, Alexander Singer
Early identification of frailty can decrease end-of-life costs while
increasing quality of life. At a minimum early identification of frailty is patient-
centred since clinicians can begin a dialogue about treatments and dying at
home. More work is needed in consistent and accurate detection of frailty or
those at risk of becoming increasingly frail both at a clinical practice panel and at
a population level. Identifying those who are frail in primary care as well as in
communities could enable targeted communications with patients and families
and community based resources in order to improve patient care, patients' and
caregivers' quality of life and better use of the healthcare system.
The goal of this work is to support healthy aging and the needs of older adults.
The specific objectives of this study are to: (a) identify administrative and
electronic medical record data derived algorithms of frailty in community dwelling
seniors (aged 65 years and older); (b) conduct content, face, and predictive
validation of the administrative and electronic medical record frailty algorithms by
engaging primary care clinicians and patients; and (c) identify natural ranges of
frailty associated with differential risks of experience a hospital-related event.
This study will take place using administrative and electronic medical
record data in the provinces of British Columbia, Alberta, and Manitoba.
We engage primary care clinicians in developing ways to identify frailty. We
engage patients in our integrated knowledge translation and exchange.