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IntroductionMany patients experience fundamental breakdowns in the healthcare system as they transition between hospital and home and do not get follow-up care they need. These patients lack confidence in the delivery of healthcare and feel completely alone with little support after discharge. This issue has been amplified with the arrival of COVID-19. To improve health system integration and health outcomes, empowering patients to identify their own care needs and preferences is critical. In Alberta, Canada, a patient led group called the Patient Transitions Resources Team (PTR) has been collaborating with healthcare teams to develop person-centric resources for patients and families. Aims Objectives Theory or MethodsAs part of the COVID-19 response, Alberta Health Services (health services delivery arm; AHS) called upon the PTR team to develop a person-centric discharge planning tool for hospitalized COVID-19 patients to reference as they transition back to their communities. Over an 8-week period, the team created the prototype, reviewed related literature, drew upon their own lived experiences, and conducted intensive interviews with patients and families. Patients and PTR team members engaged in a true partnership, building a foundation of trust, shared accountability, respect, and collaborative purpose, resulting in a united team with common vision and passion for the work. Highlights or Results or Key FindingsThe discharge planning tool, My Next Steps, has been distributed to all acute care hospitals in Alberta and is available on a provincial patient portal called MyHEALTH Alberta. The checklist was designed by patients for patients, written in plain and readily understandable language. It serves as a guide to empower patients to clearly understand what they can do and expect during their transition (e.g., points for conversations with your doctor/health team). Empathy for patients during transitions is key; while providing guidance to empower them to be fully involved in their return to health. The checklist content is acknowledged by AHS as vital to safer transitions from hospital. Key success factors of this work included AHS team members engaging with patients in a true partnership to empower patient leads as equal decision-makers to develop resources and tools which fit their needs and better support patients and families on their healthcare journey. ConclusionsThis patient-led collaborative work provided valuable lessons about co-design processes that can be shared with other teams looking to empower patients and families in their own care, and integrate the patient voice to advance person and family-centered care to support high quality transitions. Implications for applicability/transferability sustainability and limitations My Next Steps is now being used by the PTR team to create a generic discharge tool (i.e., not COVID specific) for patients and families transitioning from hospital to home. This new version will be adopted across all Alberta’s acute care hospitals, embedded within a new provincial electronic health system.

Introduction Patients with complex, chronic diseases frequently have unmet care needs as they transition between hospital and home, and often return to hospital and emergency department (ED) due to post-discharge complications. Some evidence suggests readmissions and ED usage can be prevented with appropriate primary care follow-up and community supports. The objective of this initiative was to co-design transition in care guidelines, focusing on home to hospital to home transitions, in Alberta, Canada. The guidelines aim to integrate patients’ transition journey and facilitate quality post-discharge follow-up in primary and community care, identified as critical for inclusion when designing solutions to optimize transitions. Methods Over a one year period, the Primary Health Care Integration Network led a collaborative process with key stakeholders to design content for transition in care guidelines. We followed an iterative mixed-method approach where stakeholder’s perspectives from one phase were used to inform the next phase, leading to consensus (i.e., state of agreement). Methods described for this initiative include: i) literature review ii) learning collaborative; iii) co-design collaborative, iv) patient advisor group, v) targeted online surveys, vi) stakeholder interviews, and vii) adapted modified Delphi panel. Results A knowledge product containing best evidence was developed. The following components of a patients’ transition from home to hospital to home include: Confirmation of the Primary Care Provider, Admit Notification, Discharge Planning Process, Referral and Access to Community Supports, Transition Care Plan, and Follow-up to Primary Care. The guidelines contain the activities of leading operational practice(s) including patient and family caregiver accountabilities, change management actions, potential benefits, and additional information to consider, as well as related tools and resources to support implementation. Discussions and Conclusions Key findings include a shared care model for transitions designed by and for primary care and community healthcare providers with extensive input from stakeholders including specialists, patients, families, and caregivers. This work is the result of an integrated approach for trans-disciplinary providers to collaborate and inform the design of a provincial standard for shared transition planning, and enhanced informational continuity across healthcare settings. Lessons learned Stakeholders were provided multiple opportunities to share their expertise and co-design transition in care guidelines. Providing a shared space for traditionally divergent groups such as specialists, family physicians and patients to integrate shared care models and collaboratively work towards more feasible and efficient approaches to care, was identified as a critical enabler for this work. Limitations Building consensus across a diverse group of stakeholders with varying perspectives is complex; there is no “one size fits all approach” to co-design, thus key stakeholders and contextual factors may differ across geographical settings. Suggestions for future research The development of the guidelines brought stakeholders together in a collaborative process crossing geographic, professional, and organizational boundaries. Implementation strategies for delivery of integrated care initiatives, such as the guidelines, provide additional opportunities for research. It is critically important to explore various strategies when designing local solutions for local problems, a necessary condition if the system of care is going to realize the potential articulated by this initiative.

In Alberta, no standardized processes exist to identify patients with chronic diseases (CDs) who do not have a family physician. This study examined the association between relational continuity (continuity of care) and healthcare utilization patterns in this population. Relational continuity was assessed using health administrative data to calculate a Usual Provider Continuity (UPC) Index. The majority of patients with no or a low UPC Index were male, did not have CD and were healthy or non-users of healthcare. When grouped by UPC Index, regression modelling revealed that emergency department visits and unplanned hospitalization declined with increased continuity of care. Advanced state of disease(s) and location of residence increased the likelihood of utilization of these services in the low- and moderate-continuity groups.

KEY POINTS Canadian health care needs reform,[1][1] as evidenced by its poorer rankings than other nations with respect to access, safety, quality and health outcomes, as well as particularly poor performance on timely communication between hospitals and family physicians.[2][2] Furthermore, aging

Health systems across Canada are embarking on initiatives to enhance access to primary care services, with the intent of improving patient outcomes and mitigating escalating healthcare costs. However, it is important that such initiatives be carefully weighed with the evidence that the changes will indeed have the desired impact. In Alberta, part of the informative process involved an analysis to examine links between continuity with primary care and utilization of acute care services. The findings provide information regarding expectations for outcomes and potentially useful (and not so useful) measures for monitoring progress and performance.

Introduction: Many jurisdictions in Canada are exploring the role of primary health care in mitigating the challenges of increasing and unsustainable reliance on acute care services. In the province of Alberta, several projects are underway to examine the links between use of primary health care services, patient outcomes and utilization of acute care services - work that may potentially inform policy direction. The current analysis examined the impact of continuity with primary health care services on acute care utilization among an inpatient population.Methods: Data were extracted from five administrative data sources for Alberta residents 18 years and older who were discharged to home after their first acute care inpatient encounter in 2016/17. Relational continuity was assessed in the 3 years prior to hospitalization, thus the sample was restricted to patients who were continuously registered with the Alberta Health Care Insurance Plan during that period. After exclusion of deaths in the 30 days post-discharge, 180,657 patients remained for this analyses. Continuity was calculated for patients with at least 3 physician visits using the Usual Provider Continuity (UPC) index, with the provider defined as a primary care clinic. Continuity was categorized as high (≥80%), moderate (50-79%), low (

ObjectivesChanges in physician reimbursement policies may hinder the collection of billing claims in administrative databases. Various provincial academic alternative payment programs (APPs) use incentive- or punitive-based tools to motivate physicians to submit billing claims called shadow billings; however, these incentives are not well documented in the literature. We conducted a nation-wide survey and semi-structured face-to-face interviews in Alberta, Canada to determine existing policies and guidelines for incentivizing and promoting physician billing practices. ApproachMail and online surveys were sent out to academic department head physicians in the following provinces: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Prince Edward Island and Newfoundland and Labrador. Face-to-face interviews were conducted in the province of Alberta with managers, government stakeholders, and physicians/administrators from academic APPs and Fee-for-Service plans. Face-to-face interviews and responses by mail and email submission were summarized using content analysis grouped by question type. ResultsIn total, there were 46 respondents (15 interviews, 26 mail/online). Content analysis revealed three primary perspectives, grouped at the level of individual physician, academic, and government. Across all of these unique perspectives, three primary themes emerged: 1) governance; 2) accountability; and 3) funding. Within these themes, findings were categorized as either (a) instruments or tools to promote physician billing in AAPPs; (b) enabling factors to support physician billing in AAPPs; and, (c) constraining factors impeding physician billing in AAPPs. ConclusionAccording to the majority of our respondents, financial disincentives (i.e. income at risk, financial clawbacks) appear to be most effective as a mechanism to motivate physicians within an academic APP to submit their billings. However, key barriers to successful implementation and delivery of academic APPs include a lack of alignment between government stakeholders, academic leadership and APP physician members and differences in the organizational and accountability structures of APP plans between academic facilities. It is necessary in moving forward to achieve commonly defined standards and frameworks between the various APP models across provinces and academic institutions.

ObjectivesIn Canada, secondary sources of health information such as physician billing claims are used for surveillance of chronic conditions such as hypertension. The value of this data may be affected by different types of physician payment models. Fee-for-service (FFS) physicians submit billing claims in order to be remunerated whereas physicians on salary or capitation also called alternative payment plans (APP) are remunerated regardless of whether claims are submitted. Thus there are concerns nationally that APPs may be associated with decreased frequency of billing submission, thereby eroding data quality and leading to underestimates of disease burdens and outcomes. We assessed the impact of APPs on hypertension prevalence, mortality and cardiovascular (CVD) hospitalization in Alberta. ApproachThe following health administrative databases from Alberta, Canada were used in this study: 1) Alberta Health Care Insurance Plan registry; 2) Hospital Discharge Abstract database (DAD); 3) Physician claims data and; 4) Vital Statistics database. We defined patients with hypertension aged 20 years and older between April 1, 2004 and March 31, 2009 (fiscal years 2004 to 2009) based on previously validated algorithm. Cases were then sorted into FFS and non-FFS billing status. Descriptive statistics for age group, sex, income quintile, rural/urban geographical location, death status and comorbidities were reported between the shadow billing and non-shadow billing groups in regards to prevalence, all-cause mortality and CVD hospitalizations. ResultsA total of 613, 844 adult hypertensive cases were captured during the 5 year study period. The majority of hypertension cases (99.6%, n=610,167) were identified through FFS claims. The effect of non-FFS billing estimates represented a small proportion of hypertension cases (0.40%, n=3677) identified during the study period. Among the FFS claims, overall hypertension prevalence was 22.2% (n=610167) and the effect of non-FFS billing estimates (0.13%, n=3677) on prevalence estimates was relatively minor. All-cause mortality 33.8 (95% CI 33.6-34) and CVD 40.6 (40.4-40.9) were higher for FFS cases than non-FFS cases 19.0 (16.6-21.8) and CVD: 8.0 (6.4-9.8). ConclusionDuring the study time period, the impact of non-FFS (i.e. shadow billings) on physician claims may not have impacted hypertension prevalence estimates greatly. Since Alberta uses shadow billing incentive programs, future research is needed to determine whether incentive programs should be considered in other provinces or nationally in order to preserve the overall quality of physician claims data.