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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Enrollment
180
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.
Control group will be provided a tailored list of resources
St. Michael's Hospital
Toronto, Ontario, Canada
RECRUITINGEmotional Distress on the PROMIS-29 Profile c2.1 Scale
Measure of emotional distress as measured by anxiety and depression systems
Time frame: 3 months
Social needs met
Number of social needs experienced by patients from a list (yes/no) at baseline and 3 month follow up
Time frame: 3 months
COVID related outcomes (patient-reported questionnaire built for this study)
Patient-reported COVID-related clinic or hospitalization visits and COVID vaccine status captured at baseline and 3 month follow up
Time frame: 3 months
Mortality related to COVID-19 and all cause mortality
Mortality (number of deaths) data obtained from administrative data source
Time frame: 12 months
Number of hospitalizations related to COVID-19 and all cause mortality
hospitalization (number of hospitalizations) data obtained from administrative data source
Time frame: 12 months
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