title: Supporting Goal-Oriented Primary Health Care for Seniors with Complex Care Needs Using Mobile Technology: Evaluation and Implementation of the Health System Performance Research Network, Bridgepoint Electronic Patient Reported Outcome Tool.
abstract: BACKGROUND
  Older adults experiencing multiple chronic illnesses are at high risk of hospitalization and health decline if they are unable to manage the significant challenges posed by their health conditions. Goal-oriented care approaches can provide better care for these complex patients, but clinicians find the process of ascertaining goals "too complex and too-time consuming," and goals are often not agreed upon between complex patients and their providers. The electronic patient reported outcomes (ePRO) mobile app and portal offers an innovative approach to creating and monitoring goal-oriented patient-care plans to improve patient self-management and shared decision-making between patients and health care providers. The ePRO tool also supports proactive patient monitoring by the patient, caregiver(s), and health care provider. It was developed with and for older adults with complex care needs as a means to improve their quality of life.
  
  
  OBJECTIVE
  Our proposed project will evaluate the use, effectiveness, and value for money of the ePRO tool in a 12-month multicenter, randomized controlled trial in Ontario; targeting individuals 65 or over with two or more chronic conditions that require frequent health care visits to manage their health conditions.
  
  
  METHODS
  Intervention groups using the ePRO tool will be compared with control groups on measures of quality of life, patient experience, and cost-effectiveness. We will also evaluate the implementation of the tool.
  
  
  RESULTS
  The proposed project presented in this paper will be funded through the Canadian Institute for Health Research (CIHR) eHealth Innovation Partnerships Program (eHIPP) program (CIHR-348362). The expected completion date of the study is November, 2019.
  
  
  CONCLUSIONS
  We anticipate our program of work will support improved quality of life and patient self-management, improved patient-centered primary care delivery, and will encourage the adoption of goal-oriented care approaches across primary health care systems. We have partnered with family health teams and quality improvement organizations in Ontario to ensure that our research is practical and that findings are shared widely. We will work with our established international network to develop an implementation framework to support continued adaptation and adoption across Canada and internationally.
authors.affiliation: Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. csteele@bridgepointhealth.ca.
authors.forename: Carolyn
authors.identifier: http://orcid.org/0000-0002-2146-0001
authors.initials: C
authors.lastname: Steele Gray
authors.forename: Walter P
authors.identifier: http://orcid.org/0000-0003-2494-7031
authors.initials: WP
authors.lastname: Wodchis
authors.forename: Ross
authors.identifier: http://orcid.org/0000-0003-1128-0557
authors.initials: R
authors.lastname: Upshur
authors.forename: Cheryl
authors.identifier: http://orcid.org/0000-0002-9986-3863
authors.initials: C
authors.lastname: Cott
authors.forename: Brian
authors.identifier: http://orcid.org/0000-0001-9581-0468
authors.initials: B
authors.lastname: McKinstry
authors.forename: Stewart
authors.identifier: http://orcid.org/0000-0002-1703-3664
authors.initials: S
authors.lastname: Mercer
authors.forename: Ted E
authors.identifier: http://orcid.org/0000-0003-1609-2280
authors.initials: TE
authors.lastname: Palen
authors.forename: Tim
authors.identifier: http://orcid.org/0000-0002-9986-3863
authors.initials: T
authors.lastname: Ramsay
authors.forename: Kednapa
authors.identifier: http://orcid.org/0000-0003-4738-8447
authors.initials: K
authors.lastname: Thavorn
keywords: complex care needs; cost-effectiveness analysis; eHealth/mHealth solutions; goal-oriented care; health outcomes; implementation; patient-centered care; pragmatic trial; primary health care; seniors