On this page:
Support and empower patients, families and providers throughout the transition journey.
A DiseAse-inclusive Pathway for Transitions in Care (ADAPT) is a grant-funded embedded implementation initiative for the Home to Hospital to Home Transitions Guideline (H2H2H).
In April 2020, the Alberta Health Services’ (AHS) Primary Health Care Integration Network (PHCIN) received a Partnership for Research and Innovation in the Health System (PRIHS) grant by Alberta Innovates. This 3-year grant will provide $1.2 million to improve transitions in care for patients in Alberta.
The ADAPT study is focused specifically on implementing 3 of the 6 H2H2H Guideline elements (admit notification, transition planning & follow-up to primary care) to support transitions in care for Albertans with the following 5 complex chronic conditions: heart failure, chronic obstructive pulmonary disease, cirrhosis, end-stage kidney disease and/or stage 3-4 cancers. Implementation of the 3 Guideline elements will be tested in 5 acute care sites and Primary Care Networks across Alberta.
The ADAPT project will standardize patient transitions by integrating, spreading, and scaling current disease-specific transitions in care pathways work across Alberta for patients with chronic disease. ADAPT aims to strengthen the hospital admission, transition planning, and follow-up to primary care processes. This project will also assess whether such a pathway adapted to local settings is an efficient and cost-effective intervention within the Alberta healthcare system.
Patients who have complex, chronic diseases often have extensive unmet care needs as they transition between hospital and home and regularly return to hospital due to a flare-up or progression of their medical condition. Many re-admissions to hospital can be prevented with appropriate primary care and community supports. Most interventions to address care gaps during transitions in care tend to be disease-specific (e.g., heart failure, cancer) without addressing multimorbidity 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.
Opportunities exist to enhance healthcare system integration in Alberta and improve transitions in care.
ADAPT is seeking input from primary care physicians and multidisciplinary team members to co-design a standardized post-discharge follow-up process in primary care for transitioning patients with chronic disease. Broad perspectives are needed to ensure optimal design and usability across the province.
Read more about participating in the co-design of this process, Transitions and Care Planning in the Patients Medical Home If you would like more information on the project, contact email@example.com.