At-risk and vulNerable Individuals To Infection With COVID-19 and ProActive inTervention With intEgrated Health and Social Care (ANTICIPATE)

At-risk and vulNerable Individuals To Infection With COVID-19 and ProActive inTervention With intEgrated Health and Social Care

At-risk and vulNerable Individuals To Infection With COVID-19 and ProActive inTervention With intEgrated Health and Social Care (ANTICIPATE): a Pragmatic Randomized Controlled Trial

Ontario Ministry of Health and Long Term Care, Ontario Medical Association, Platinum Medical Clinic, Markham Family Health Team, Barrie and Community Family Health Team, University of Toronto Practice Based Research Network

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.

Participants will be randomized into "intervention" or "control" group. The intervention group will be connected to a system navigator who is a trained staff member embedded within the primary health clinic team with a focus to address participant's biological, psychological and social needs. Control group will be provided a tailored list of community resources.

The intervention group will be connected to a system navigator who is a trained staff member embedded within the primary health clinic team with a focus to address participant's biological, psychological and social needs. Working with the System Navigator will mean: Discussing patients' current health status and concerns Receiving support on management of chronic diseases and mental health including connection to local resources e.g. counseling, harm reduction, crisis support services Receiving information about benefits that they may be entitled to and learning about free services Receiving help from the System Navigator on forms or letters that are required to access resources

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.

Number of social needs experienced by patients from a list (yes/no) at baseline and 3 month follow up

Patient reported COVID related clinic or hospitalization visits captured at baseline and 3 month follow up

Inclusion Criteria: At-risk and vulnerable patients of primary care organizations who are 60+ AND have one or more of: chronic condition (diabetes, CHF, CAD, COPD or asthma) serious mental illness (schizophrenia or bipolar disorder) anticipated to live in poverty and/or be homeless/underhoused Exclusion Criteria: patients unable to provide informed consent