Complex Patients in Primary Care

Complex Patients Require Coordinated Care

People with complex conditions often experience gaps in care after discharge, placing growing pressure on primary care teams. Primary care teams are increasingly expected to support these patients, yet frequently lack the capacity, tools, and integrated support necessary to do so effectively. This project was initiated by The Toronto Western Hospital Family Health Team led by Dr. Ben Kaasa and the TWH Clinical Administration led by Sabrina Bennett to explore the barriers faced by primary care teams and how they intersect with the needs of UHN patients. Transplant recipients have been identified as the first target patient population by team members. Post-transplant care is delicate, complex, and life-long—it requires vigilant care and attention from multiple providers and thus represents a key first beneficiary from this exploration.

Current State

Post-transplant, patients end up seeing transplant specialists in the hospital for issues that would be more appropriately addressed in the community by their primary care provider, who can offer continuity and understand the patient’s broader health context beyond transplant-specific issues. This has several negative impacts, including limiting the capacity of transplant specialists to see new patients requiring specialist care, which in turn impacts wait times. As a result, the pathway can become less efficient, less coordinated, and less aligned with what patients and providers need.

Our Goal

Through this project, the UHN OpenLab team aims to identify key gaps experienced by patients and link them to resources or supports needed by transplant specialists as well as primary care. By triangulating these issues we aim to propose a new way of supporting transplant patients that can be implemented by UHN to improve patient care.

Get in Touch

Are you a primary care doctor or transplant recipient interested in speaking to us? Send us an email at research@uhnopenlab.ca to schedule an interview.