Toward more integrated careThe goal of integrated care is to ensure that the continuity and comprehensiveness of care provided by different professionals in different organizations are linked to the specific needs of each patient. and better self-managementSelf-management is the development and acquisition of the skills necessary to manage one’s own health care. for people with chronic illnessesChronic illnesses are conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living. who have complex health needsPeople with complex health needs must be able to access care that addresses chronic, mental health and medication issues as well as social vulnerability. and are at risk of high health and social services utilization.Uncoordinated, repetitive use of health care services through frequent emergency department visits or hospitalizations.
A growing number of people have multiple chronic conditions. Mental health problems, poverty or social exclusion can result in complex health needs, which can put them at risk of high utilization of the health and social services system.
The work of the V1SAGES research team aims to improve:
- the experience of care of these individuals
- the health status of these individuals
- the teamwork of professionals
- the efficiency of the health and social services system