Opportunities - Integrated Supportive Care: Improving Care for Patients with Advanced Chronic Illness & Cancer Within Their Home Communities

Project Background


The Integrated Supportive Care Initiative focuses on providing better support in the community for patients with advanced stage chronic diseases. By involving patients in care planning,  the program aims to improve healthcare experience, patient satisfaction, and communication between healthcare providers, patients, family, and caregivers.


The Integrated Supportive Care Initiative aims to enhance home and community-based care across Alberta, especially in rural areas, for frail patients with advanced stage chronic diseases who are unlikely to benefit from aggressive treatments. Through patient-informed innovative, sustainable changes to health service delivery, patients with chronic conditions will be supported to receive the right care, in the right place, at the right time, by the right health team.  This can lead to improved patient experience and outcomes, and reduced costs and utilization of health care system resources.


Patients living with advanced stage chronic diseases will benefit by receiving an enhanced care plan they can share with their care team. This will include access to resources and educational materials such as:

• Interactive patient decision aids that have been co-developed around important and  challenging treatment decisions. An example could be: “Is dialysis right for me?”; “Will a left ventricular assist device help me?”.

• Tools to help patients with advanced stage chronic diseases make decisions about the care they desire.

• Enhanced community supports such as end-of-life care and crisis management.


We will be hosting World Café style focus groups to gather patient input in developing these care plans, resources and educational materials.  A World Café is used to bring people together to discuss a topic they have in common.

The first World Café will take place in Edmonton on Thursday, October 17; this will take about 4 hours and cover 4 key topics about care for patients with complex chronic illnesses.


Hearing about your experiences, what you need, and what works and does not work will help us to improve care for patients with chronic conditions. Your input will help us understand what matters most to you when you interact with your health care team.


Roles and Responsibilities

We are looking for patients and caregivers with experience with one, or more, of the following complex chronic illnesses:

  • lung, liver, kidney disease, heart failure, or cancers

and who require frequent visits to a family doctor, the hospital, or emergency department for these conditions.


Your valued input and lived-experience will help us to:

  • Develop educational materials and support to improve patient experience and      outcomes
  • Build a living care plan that is shared between a patient and their healthcare team that reflects patient/family needs, preferences and goals and involves patients in making decisions about the care they receive


Time Commitment

The first World Café will take place in Edmonton on October 17th at 12:00 – 4:00 pm and will be exclusive to patients and those who help care for them at home (i.e. family members, caregivers, etc.).

If you are unable to attend in Edmonton on October 17th, additional World Cafes will be held in December and January in Edmonton, Red Deer and Calgary to bring together patients, caregivers and health providers.


Reimbursement /Compensation

Light lunch and refreshments will be served at the October 17 event.

Reimbursement will be provided for parking to attend.

Reimbursement will be provided for mileage or bus fare to travel.




For more information or to register to attend please contact:


Kirby Scott, Senior Project Manager