The aim of Patient-Centred Innovations for Persons With Multimorbidity (PACE in MM) study is to reorient the health care system from a single disease focus to a multimorbidity focus; centre on not only disease but also the patient in context; and realign the health care system from separate silos to coordinated collaborations in care. PACE in MM will propose multifaceted innovations in Chronic Disease Prevention and Management (CDPM) that will be grounded in current realities (i.e. Chronic Care Models including Self-Management Programs), that are linked to Primary Care (PC) reform efforts. The study will build on this firm foundation, will design and test promising innovations and will achieve transformation by creating structures to sustain relationships among researchers, decision-makers, practitioners, and patients. The Team will conduct inter-jurisdictional comparisons and is mainly a Quebec (QC) - Ontario (ON) collaboration with participation from 4 other provinces: British Columbia (BC); Manitoba (MB); Nova Scotia (NS); and New Brunswick (NB). The Team's objectives are: 1) to identify factors responsible for success or failure of current CDPM programs linked to the PC reform, by conducting a realist synthesis of their quantitative and qualitative evaluations; 2) to transform consenting CDPM programs identified in Objective 1, by aligning them to promising interventions on patient-centred care for multimorbidity patients, and to test these new innovations' in at least two jurisdictions and compare among jurisdictions; and 3) to foster the scaling-up of innovations informed by Objective 1 and tested/proven in Objective 2, and to conduct research on different approaches to scaling-up. This registration for Clinical Trials only pertains to Objective 2 of the study.
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Evaluation of Intervention Effectiveness - Change in Self-Management outcomes
Timeframe: T1: Initial evaluation; T2: after 4 months; T3: one year after T2;
Evaluation of Intervention Effectiveness - Change in Transitions of Care
Timeframe: T1: Initial evaluation; T2: after 4 months; T3: one year after T2;
Evaluation of Intervention Effectiveness - Change in Self-Efficacy
Timeframe: T1: Initial evaluation; T2: after 4 months; T3: one year after T2;
Evaluation of Intervention Effectiveness - Change in Patient-Centredness
Timeframe: T1: Initial evaluation; T2: after 4 months; T3: one year after T2;