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Matthew James

Bridging Community and Acute Care Lead

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Neesh Pannu

Bridging Community and Acute Care Lead

Bridging Community and Acute Care

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This research theme brings together researchers, decision-makers, and digital health innovators to ensure seamless, inclusive, and scalable healthcare implementation in acute and community-based care settings.

Key Areas of Focus

Our work targets critical areas where digital innovation can improve how care is delivered, coordinated, and experienced across the system

01. Focus Area 
02. Focus Area 
03. Focus Area 

FEATURED PROJECTS

Storyboards From the
2024 Innovation Gallery

Explore featured storyboards that bring to life the real-world challenges, bold ideas, and digital health innovations shaping the future of care in Alberta.

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Improve CV Care

Patients and physicians currently face challenges in effectively discussing non-physiological factors that impact cardiovascular health—such as mental health, support systems, and medication affordability—within the limited time available in appointments. This lack of structure can lead to tunnel vision, where only immediate physiological symptoms are prioritized, leaving other crucial aspects unaddressed.

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Pressure Wound Staging App

An audit of Alberta’s acute care sites revealed that about one in six patients had a hospital-acquired pressure injury. These injuries cause painful, rapidly progressing sores that can lead to severe complications and even death. Pressure injuries are seen as an important indicator of healthcare quality. A high number of these injuries may indicate systemic problems with how care is being provided. Accurate staging and assessments are crucial in wound care as they ensure the right treatment plan is applied, which is vital for effective healing and avoiding further complications.

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Presuna: Empowering Remote Point-of-Care Ultrasound Imaging

Point-of-care ultrasound (POCUS) is a portable, non-invasive tool that offers real-time imaging. This, along with its ease of use, is expected to play a vital role in home-based care and remote locations. Advancements in handheld technology have enabled POCUS to integrate into programs like Hospital at Home, enabling faster and more accurate diagnoses in patient homes. Presuna, a cloud-based software, enhances POCUS by enabling clinicians to send and interpret ultrasound images remotely. It facilitates remote assessments and improves decision-making for conditions like CHF and COPD in home-based care settings. Beyond clinical use, it acts as an educational tool, tracking training progress to help physicians monitor provider skill development.

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PAUSE: Preventing medication complications during Acute illness through Symptom Evaluation and sick day guidance 

The PAUSE app is a digital tool designed to help patients manage their medications safely during times of illness. By providing personalized, symptom-based guidance, the app instructs users on when to temporarily stop or restart medications, helping to prevent complications. Many corporate pharmacies now offer digital apps for accessing prescriptions, which creates new opportunities for providers across Alberta. The PAUSE team is developing an app that integrates with the industry, aiming to bring innovative self-management tools to the community.

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UPTAKE

Acute Kidney Injury (AKI) causes long-term complications like cardiovascular issues and hospital readmissions. Rapidly developing and often under-managed, AKI poses risks when follow-up care is lacking. Many patients leave the hospital unaware of their condition or next steps. The UPTAKE platform (Using Personalized risk and digital tools for Transitions in care after Acute Kidney Events) delivers tailored after-visit summaries with AKI-specific information, follow-up instructions, and guidance, improving care continuity and empowering patients. 

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The Integrated Care Pathway

In Canada, adults with multiple chronic conditions represent 30% of healthcare spending, with frequent and costly readmissions emphasizing the need for models that reduce hospital dependency and enhance care continuity. The Integrated Care Pathway (ICP) aims to improve care management and continuity of care for complex inpatients in the Calgary Zone by redesigning existing roles. This project is endorsed by AHS as part of the Acute Care Bundle Improvement initiative and is modelled after UHN's Connect Care model, with the evaluation led by Dr. Karen Okrainec.

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Coming Soon!

APPROACH

Coming Soon!

Pressure Wound Staging App

Coming Soon!

IMPROVE CV Care

Coming Soon!

UPTAKE

Coming Soon!

Integrated Care Pathway (ICP) Evaluation

Coming Soon!

UPTAKE VC

Coming Soon!

PAUSE

THEME ONE

Our Projects
Theme Leads
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