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| Name | Class |
|---|---|
| Ontario Ministry of Health and Long Term Care | OTHER_GOV |
| Ontario Medical Association | OTHER |
| Platinum Medical Clinic | UNKNOWN |
| Markham Family Health Team |
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This randomized control trial aims to explore a data-driven, proactive approach to identifying patients at greatest risk during the pandemic, and assess the impact of an embedded System Navigator in a primary health care setting. The System Navigator works one-on-one with patients to identify and provide support to their biological, psychological and social needs (e.g. income, housing, food security). Investigators are doing this study to find out whether proactive identification of vulnerable patients and linking to a System Navigator leads to reduction in emotional distress associated with managing complex health conditions and unmet social needs during COVID-19, compared to usual care.
Investigators will involve approximately 180 patients from primary care clinics that are a part of the University of Toronto Practice-Based Research Network (UTOPIAN). The information from this study will be used to help us understand how proactive engagement within a primary health setting can help to improve the health of patients during COVID-19, and beyond.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intervention - System Navigator | Experimental | The intervention group will be connected to a system navigator who is a trained staff member embedded within the primary health clinic team with a focus to address participant's biological, psychological and social needs. Working with the System Navigator will mean:
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| Tailored list of community resources | Active Comparator | Control group will be provided a tailored list of community resources. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| System Navigator | Other | Participants will be connected to a System Navigator, who is a trained staff embedded within their primary health clinic to support and help navigate biological, psychological and social needs in proactively identified vulnerable patients. |
| Measure | Description | Time Frame |
|---|---|---|
| Emotional Distress on the PROMIS-29 Profile c2.1 Scale | Measure of emotional distress as measured by anxiety and depression systems | 3 months |
| Measure | Description | Time Frame |
|---|---|---|
| Social needs met | Number of social needs experienced by patients from a list (yes/no) at baseline and 3 month follow up | 3 months |
| COVID related outcomes (patient-reported questionnaire built for this study) |
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Inclusion Criteria:
At-risk and vulnerable patients of primary care organizations who are 60+ AND have one or more of:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Andrew D Pinto, MD, MSc | Contact | 416-864-6060 | 77350 | andrew.pinto@utoronto.ca |
| Rose Wang, MPH | Contact | 416-864-6060 | 76223 | rose.wang@unityhealth.to |
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| St. Michael's Hospital | Recruiting | Toronto | Ontario | M5B1W8 | Canada |
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| UNKNOWN |
| Barrie and Community Family Health Team | UNKNOWN |
| University of Toronto Practice Based Research Network | OTHER |
Participants will be randomized into "intervention" or "control" group.
The intervention group will be connected to a system navigator who is a trained staff member embedded within the primary health clinic team with a focus to address participant's biological, psychological and social needs. Control group will be provided a tailored list of community resources.
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| Tailored list of resources | Other | Control group will be provided a tailored list of resources |
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Patient-reported COVID-related clinic or hospitalization visits and COVID vaccine status captured at baseline and 3 month follow up
| 3 months |
| Mortality related to COVID-19 and all cause mortality | Mortality (number of deaths) data obtained from administrative data source | 12 months |
| Number of hospitalizations related to COVID-19 and all cause mortality | hospitalization (number of hospitalizations) data obtained from administrative data source | 12 months |
| ID | Term |
|---|---|
| D000092862 | Psychological Well-Being |
| D000086382 | COVID-19 |
| ID | Term |
|---|---|
| D010549 | Personal Satisfaction |
| D001519 | Behavior |
| D011024 | Pneumonia, Viral |
| D011014 | Pneumonia |
| D012141 | Respiratory Tract Infections |
| D007239 | Infections |
| D014777 | Virus Diseases |
| D018352 | Coronavirus Infections |
| D003333 | Coronaviridae Infections |
| D030341 | Nidovirales Infections |
| D012327 | RNA Virus Infections |
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
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