Achieving the quadruple aim: An assessment of a participatory approach to developing individual patient-centred care plans for community-care services

PHSS Medical and Complex Care in Community (PHSS) is an organization that provides community-care services (e.g., personal support, residential housing, etc.) to people with physical and developmental disabilities and complex medical conditions. PHSS employs a patient-centered, individualized, participatory model of care. For each patient, PHSS creates patient-centred individual service agreements (ISA) and person-centred plans (PCP) through a series of discussions with the patient, and with input from family members, friends, staff, and community members. PHSS used this approach to adapt care delivery during the COVID19 pandemic, and, despite the significantly higher risks within this patient population, to date none of PHSS's patients have contracted COVID19. In this light, upstream interventions, such as the individualized participatory ISA/PCP approach used in the PHSS model of care that have effectively mitigated COVID19 risks for members of the community-care population may also be effective in addressing the health and health service inequities that exist during non-pandemic times. In this project we will interview PHSS patients (or their family) and PHSS staff to understand the key components and impacts of the individualized participatory ISA/PCP approach. We will also interview administrators of health and social care community-care organizations in Southwest Ontario. We will conduct a scoping review to identify types and features of participatory approaches, factors that support or hinder the use of participatory approaches, and evidence of effectiveness and impacts of participatory approaches. We will then create a program logic model by integrating findings from the three studies. The project responds to the urgent need for research on cost-effective upstream innovations in the community-care sector that will improve patient experiences and outcomes and address sector challenges (such as workforce issues).