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Theme 1: Bridging Community and Acute Care
Integrated Care Pathway (ICP) Evaluation
Redesigning Pathways for more centralized, holistic care
Lead
Michelle Grinman (Co-Principal Investigator)
Co-lead
Karen Okrainec (Co- Principal Investigator and Project Lead)
Additional Contributors
Sunita Chacko (Collaborator), Ceara Cunningham (Co-Investigator)
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THE CHALLENGE
In Canada, adults with multiple chronic conditions frequently rely on hospital care in the form of admissions and readmissions, with admissions accounting for nearly 30% of healthcare spending. Such patients also often experience fragmented care, limited coordination between providers, and inadequate post-discharge support. These patients move between specialists and care settings without consistent follow-up, contributing to repeated admissions, preventable complications, and poorer health outcomes. There is a pressing need for models that strengthen continuity of care, reduce hospital dependence, and improve how patients transition safely back into the community.
THE CHALLENGE
In Canada, adults with multiple chronic conditions frequently rely on hospital care in the form of admissions and readmissions, with admissions accounting for nearly 30% of healthcare spending. Such patients also often experience fragmented care, limited coordination between providers, and inadequate post-discharge support. These patients move between specialists and care settings without consistent follow-up, contributing to repeated admissions, preventable complications, and poorer health outcomes. There is a pressing need for models that strengthen continuity of care, reduce hospital dependence, and improve how patients transition safely back into the community.
THE INNOVATION
Innovation Overview Heading
HOW IT WORKS
HOW IT WORKS
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[Innovation Overview] This project focuses on understanding and addressing the technological acceptance barriers among older adults in Central Alberta. By comparing the usage and attitudes of those living independently, with partners, or in care facilities, the initiative identifies gaps and opportunities to design more inclusive, user-friendly digital health solutions.
Surveys and in-depth interviews gather insights into older adults’ experiences with existing eHealth and mHealth platforms, with a focus on their potential for improving healthcare access and supporting healthy aging.
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HOW IT WORKS
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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. This model draws on successful implementations such as the University Health Network ICP in Toronto, which provides patients with one care team, one shared record, one funding model, and one point of contact extending from hospital to home.
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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.
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
Ready to Keep Exploring?
If you’d like to learn more or connect about Integrated Care Pathway (ICP) Evaluation, reach out to Michelle Grinman, Project Lead, at:
Get Involved
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View other projects and explore the Health Everywhere Portfolio to see how local innovations are transforming care across the province.
Explore the Health Everywhere Portfolio to see how local innovations are solving real-world challenges and shaping the future of care across the province.
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The Health Everywhere Hub portfolio map showcases academic-led projects tackling real healthcare challenges across Alberta. By highlighting shared goals and commonalities, we hope to spark collaboration and amplify impact across the system.
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