The COVID-19 pandemic significantly impacted primary care across Canada. Inequities inprevention activities and chronic disease management likely increased but the extent isunknown. Pragmatic interventions are required to prioritize patients and improve thequality of primary care post-COVID. In AFTERMATH, the investigators will conduct apragmatic cluster randomized controlled trial (cRCT) at the largest primary carePractice-Based Research Network (PBRN) in Ontario, focused on a highly marginalizedpopulation: adults living with mental illness and one or more additional chronicdiseases. The investigators will test an intervention that builds on the investigators'past work and combines data and supports to primary care providers to improve quality oflife, reduce gaps in prevention activities and improve chronic disease management. Theinvestigators' project will result in new evidence on ways to improve access to care andreduce inequities, and inform future efforts to use data beyond COVID-19.
Not Provided
Other: Community Health Worker
Physicians will work with a Community Health Worker (CHW) to review the data presented in
their Quality Improvement reports, and triage patients for proactive outreach (e.g. "No
action necessary", "Call patient to check-in", "Arrange BP, weight and labs", "Book for
phone appointment", "Book for in-person appointment").
Inclusion Criteria:
A. Family Physicians: Any family physician in the University of Toronto Practice-Based
Research Network (UTOPIAN) with 10+ community-dwelling patients living with depression,
schizophrenia or bipolar disorder plus one or more additional chronic disease (COPD,
diabetes, hypertension, osteoarthritis, dementia, epilepsy and Parkinson's).
B. Patients: Patients from the included family physician practices living with
depression, schizophrenia or bipolar disorder plus one or more additional chronic disease
(COPD, diabetes, hypertension, osteoarthritis, dementia, epilepsy and Parkinson's).
Exclusion Criteria:
A. Family Physicians: None
B. Patients: Patients under 18
Not Provided
Antonio Cassano, BA
416-864-6060 - 40218
antonio.cassano@unityhealth.to
Andrew Pinto, MD MSc
416-864-6060 - 76148
andrew.pinto@utoronto.ca
Andrew Pinto, MD MSc, Principal Investigator
Unity Health Toronto