| Study new value-added models of health care that include assessment and interventions for social determinants |
Using standardized methods to assess social determinants Using geographic information system tools that map patient population by deprivation, disease, and possible environmental factors, which will then be incorporated into practice management tools Understanding the cost-effectiveness of intervening on social determinants of health to inform new payment models and rates Targeting inequities experienced by some populations (eg, First Nations, low-income communities, minorities, refugees, asylum seekers and other migrants)
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| Develop better methods of risk stratification and adjustment measures that include measures of deprivation and equity |
Completing better mapping of subpopulations at varying degrees of risk geographically Determining better ways to target high-risk groups for care management and other intensive interventions and to tailor risk interventions Exploring better ways to equitably allocate health care dollars based on the complexity of the population served
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| Elucidate the links between health literacy and inequities and develop interventions to address health literacy |
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| Develop, implement, and evaluate models for primary care management of multiple chronic conditions (eg, intensive primary care) |
Determining what the essential additional resources are for primary care to optimize experiences and outcomes for patients with multiple chronic conditions Exploring how to provide low-cost home care and link it to primary care Examining how to sustainably integrate community care, social services, and public health with primary care Determining how to integrate and coordinate care as individuals transition across care settings (specialty care, acute care, postacute care, etc)
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| Develop and evaluate methods to identify priorities, goals, and outcomes of relevance to patients with multiple chronic conditions |
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| Identify the conditions needed to create and sustain successfully functioning health care teams to support patient-centred primary care |
Identifying the environmental characteristics, training, funding, and organizational models that are needed to create and sustain patient-centred primary care
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| Identify how different features of primary care perform, respond to, or are incentivized by different payment models |
Identifying the effect of different methods of activity-based, population-based, and quality- and outcome-based funding on access to and coordination, comprehensiveness, and continuity of care
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| Identify effective means for patient engagement (eg, patient or family advisory council) |
Co-creating system transformation Considering the design and delivery of care Including patient-to-patient mentoring Addressing social determinants as a collective
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| Identify effective approaches to providing performance feedback on quality and equity and facilitate changes in practice |
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| Develop new methods to produce timely, unbiased evidence in rapidly evolving systems |
Considering some combination of quality improvement strategies and new research methods, natural experiments, and pragmatic trials, as standard randomized controlled trials do not work and 3–5 years is too long Considering mixed-method approaches to understand model effects and how new models are implemented Understanding model components and population subsets
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