Bridging Community and Acute Care
Integrated Care Pathway (ICP) Evaluation
Redesigning Pathways for More Centralized, Holistic Care
Lead
Michelle Grinman
Co-Lead
Karen Okrainec
Additional Contributors
Sunita Chacko, Ceara Cunningham
Share this project
Share this project
Bridging Community and Acute Care
Integrated Care Pathway (ICP) Evaluation
Redesigning Pathways for More Centralized, Holistic Care
Lead
Michelle Grinman
Co-Lead
Karen Okrainec
Additional Contributors
Sunita Chacko, Ceara Cunningham
Share this project
THE CHALLENGE
In Canada, adults with multiple chronic conditions rely heavily on hospital care, with admissions and readmissions accounting for nearly 30% of healthcare spending. These patients often face fragmented care, limited coordination among providers, and inadequate post-discharge support. As they move between specialists and care settings without consistent follow-up, they are at higher risk of repeated admissions, preventable complications, and poorer health outcomes.
THE CHALLENGE
In Canada, adults with multiple chronic conditions rely heavily on hospital care, with admissions and readmissions accounting for nearly 30% of healthcare spending. These patients often face fragmented care, limited coordination among providers, and inadequate post-discharge support. As they move between specialists and care settings without consistent follow-up, they are at higher risk of repeated admissions, preventable complications, and poorer health outcomes.
THE CHALLENGE
In Canada, adults with multiple chronic conditions rely heavily on hospital care, with admissions and readmissions accounting for nearly 30% of healthcare spending. These patients often face fragmented care, limited coordination among providers, and inadequate post-discharge support. As they move between specialists and care settings without consistent follow-up, they are at higher risk of repeated admissions, preventable complications, and poorer health outcomes.
THE INNOVATION
The Integrated Care Pathway (ICP) is a structured, team-based model designed to improve discharge planning, continuity of care, and post-discharge support for high-risk, medically complex patients in the Calgary Zone. Each patient is connected to an Integrated Care Lead (ICL) who coordinates complex discharge planning, streamlines communication between hospital and home, and links patients to community and primary-care supports. The ICL follows patients for up to 90 days after discharge, with frequent check-ins during the critical first 1–2 weeks when the risk of ED visits or readmission is highest. Patients also have access to a 24/7 phone line—delivered in partnership with HealthLink—for urgent guidance and clinical navigation.
THE INNOVATION
The Integrated Care Pathway (ICP) is a structured, team-based model designed to improve discharge planning, continuity of care, and post-discharge support for high-risk, medically complex patients in the Calgary Zone. Each patient is connected to an Integrated Care Lead (ICL) who coordinates complex discharge planning, streamlines communication between hospital and home, and links patients to community and primary-care supports. The ICL follows patients for up to 90 days after discharge, with frequent check-ins during the critical first 1–2 weeks when the risk of ED visits or readmission is highest. Patients also have access to a 24/7 phone line—delivered in partnership with HealthLink—for urgent guidance and clinical navigation.
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HOW IT WORKS
The ICP assigns a dedicated Integrated Care Lead who supports patients from hospital admission through 90 days post-discharge. The model includes coordinated discharge planning, personalized care plans in the EMR, proactive phone follow-ups, a 24/7 support line via 811HealthLink, and connections to primary care, home care, and community services to ensure seamless transitions.
HOW IT WORKS
The ICP assigns a dedicated Integrated Care Lead who supports patients from hospital admission through 90 days post-discharge. The model includes coordinated discharge planning, personalized care plans in the EMR, proactive phone follow-ups, a 24/7 support line via 811HealthLink, and connections to primary care, home care, and community services to ensure seamless transitions.
THE BENEFITS
For Users
Enhanced Support and Follow-Up: Patients receive ongoing guidance after discharge, improving their ability to manage chronic conditions at home.
Improved Continuity of Care: Tailored follow-up and coordinated care plans reduce care fragmentation and prevent gaps that lead to readmissions.
Greater Patient Autonomy: Patients are empowered with consistent, accessible support, strengthening their confidence and capacity to self-manage their health.
For The System
Reduced Hospitalization and Readmissions: Proactive discharge planning and post-discharge monitoring lower the likelihood of ED visits and preventable readmissions, easing pressure on acute care.
Improved Resource Efficiency: Coordinated care and streamlined case management reduce strain on hospital teams and support more efficient care delivery.
Long-Term Cost Savings: By preventing complications and avoidable hospital use, ICP supports sustainable healthcare utilization, better long-term outcomes, and health system costs
THE BENEFITS
For Users
Enhanced Support and Follow-Up: Patients receive ongoing guidance after discharge, improving their ability to manage chronic conditions at home.
Improved Continuity of Care: Tailored follow-up and coordinated care plans reduce care fragmentation and prevent gaps that lead to readmissions.
Greater Patient Autonomy: Patients are empowered with consistent, accessible support, strengthening their confidence and capacity to self-manage their health.
For The System
Reduced Hospitalization and Readmissions: Proactive discharge planning and post-discharge monitoring lower the likelihood of ED visits and preventable readmissions, easing pressure on acute care.
Improved Resource Efficiency: Coordinated care and streamlined case management reduce strain on hospital teams and support more efficient care delivery.
Long-Term Cost Savings: By preventing complications and avoidable hospital use, ICP supports sustainable healthcare utilization, better long-term outcomes, and health system costs
Get Involved
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