Research in Focus shines a light on the innovative studies and discoveries taking shape across the UBC Department of Anesthesiology, Pharmacology & Therapeutics. Through each feature, we celebrate the minds driving meaningful change in research, education, and clinical practice across anesthesiology, pharmacology, and therapeutics.
For Dr. Matthew Wiens, care doesn’t end at the hospital door—it continues in the communities where patients return.
Over the past 13 years, Dr. Wiens has led the development and implementation of a series of studies focused on deriving and validating clinical prediction models for post-discharge mortality among children with sepsis in East Africa. His research has contributed to a growing understanding of how risk can be identified early and acted upon effectively in low-resource settings.
He leads the Smart Discharges digital health research program, an initiative designed to improve patient outcomes by identifying vulnerable individuals and strengthening the transition from facility-based care to community-based support following discharge. Through this work, he aims to ensure that high-risk patients do not fall through the cracks once they leave the hospital.
Building on this foundation, his latest project, REConeCteD: Risk Enhanced Community Care after Discharge, advances a risk-differentiated care approach. By digitally linking facility-based and community-based health systems, the project enables personalized health education and targeted follow-up plans tailored to each patient’s risk profile and co-morbidities—bringing continuity of care beyond the hospital and into the community.
“REConneCteD represents a new model for pediatric care—one that recognizes recovery does not end at the hospital door, but continues in the communities where children and families live, supported by technology that connects all parts of the healthcare system.”
— Dr. Matthew Wiens, Assistant Professor; UBC, Researcher; BC Children’s Hospital Research Institute
Meet Matthew Wiens!
Site: BC Children’s Hospital Research Institute (BCCHR)
Rank: Assistant Professor; UBC, Researcher; BC Children’s Hospital Research Institute
Dr. Matthew Wiens is a global health researcher dedicated to improving sepsis outcomes in resource-limited settings. His work sits at the intersection of clinical epidemiology, prediction modelling, and digital health, where he focuses on developing practical, data-driven solutions to address critical gaps in care.
Dr. Wiens spent six years of his training, which included a PhD in Epidemiology at UBC, followed by a postdoctoral fellowship at UBC and the BC Children’s Hospital Research Institute, living and working in Uganda. Immersion in local health systems fostered a deep and continually evolving understanding of the complexity and nuance required to achieve sustainable change in resource-limited settings.
These experiences ultimately shaped his commitment to working within existing systems and workflows. Today, Dr. Wiens is driven by a passion for embedding risk-differentiated care approaches into clinical practice, approaches that support more informed decision-making and more effective resource allocation, with the goal of improving outcomes for children with sepsis.
What drew you to this particular research question or problem?
When children in East Africa recover from serious infections and leave the hospital, their journey to full health is far from over. Many of these children face a dangerous period after discharge—they remain at high risk of becoming sick again or even dying from recurring infections. Families encounter numerous barriers to caring for their child at home and are often left to navigate this high-risk period on their own, sometimes with devastating consequences. In countries such as Uganda, there have been concerted efforts to strengthen referral systems and better connect community care to facility-based care; however, the reverse is not true. Once a child is discharged from the hospital, there are often insufficient resources or strategies in place to inform home communities of the need for follow-up care.
How does this project fit into your broader research interests or goals?
The goal of the Smart Discharges and REConneCteD projects is to identify and prioritize children at the highest risk, emphasize the importance of healthy behaviors at home, support timely care-seeking, and maintain connections to the healthcare system. One way this has been facilitated is through the introduction of the electronic Community Health Information System (eCHIS)—a mobile application developed by the Ministries of Health in several African countries to digitize community health services.
By digitally linking eCHIS with a child’s electronic health record, REConneCteD helps ensure that the most at-risk children are reconnected with community health workers for follow-up after discharge. It also provides information and education to health workers, community health workers, and caregivers on the prevention, diagnosis, and treatment of childhood diseases. Rather than relying on a one-size-fits-all approach, the system enables more personalized care, ensuring that children at highest risk receive the greatest attention and resources.
What impact do you hope this work will have on clinical practice, education, or society in general?
REConneCteD represents a new model for pediatric care—one that recognizes recovery does not end at the hospital door, but continues in the communities where children and families live, supported by technology that connects all parts of the healthcare system.
At its core, the program creates a digital bridge between hospitals and community health workers. When a child is discharged, their information and care plan are securely shared with community health workers through connected digital systems, enabling timely and coordinated follow-up.
REConneCteD aims to transform post-discharge care by strengthening community health services, reducing the burden on families who face barriers to accessing follow-up care, and creating feedback loops that help hospitals continuously improve their services. By linking facility- and community-based care through digital tools, the program works to ensure that no child falls through the cracks during the vulnerable period after hospitalization.
What’s one thing you hope people will take away from this work?
The post-discharge period remains an overlooked and highly vulnerable time for children recovering from sepsis. However, by using simple risk-prediction tools, strengthening digital linkages across health systems, connecting patients to existing services, and ensuring comprehensive caregiver counselling, we can go a long way toward improving outcomes for these children.
