Coordination of chronic care between health systems and the community

The Chronic Care Model describes the need to establish links between heath care systems and the community as a component of patient-centered care. Additionally, local health networks have identified that connecting with community resources could help overcome chronic pain care fragmentations. However, determining how, when and which community components to integrate requires ongoing and deliberate involvement of a diverse group of stakeholders.

Our lab is currently conducting research on the integration of community resources, structures and policies into chronic pain management in Quebec. This work is part of a larger research project aiming to guide the development of a person-centered learning health community. It will inform the design of an integrated community program, with an evaluation guided by the Quadruple Aim framework.