Theme 1: Bridging Community and Acute Care
Integrated Care Pathway (ICP) Evaluation
A structured, team-based approach to discharge planning and post-discharge support.
Lead:
Michelle Grinman (Co-Principal Investigator)
Project Lead:
Karen Okrainec
Collaborator:
Sunita Chacko
INNOVATION STAGE
Implementation Integration
Health Innovation Focus
Chronic Disease; Health Promotion & Prevention
Population and Setting
Complex, frailty, vulnerable and/or elderly adults with or without co-morbidities
Technology and Intervention
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BENEFITS
For Users
Enhanced Support and Follow-Up: Patients receive ongoing guidance and assistance, improving their capacity to manage chronic conditions from home.
Improved Continuity of Care: Structured follow-up and tailored care plans reduce disruptions in care, promoting better management of health at home and reducing readmissions.
Greater Patient Autonomy: Patients are empowered to self-manage their conditions with accessible, ongoing support, enhancing their health outcomes and quality of life.
For The System
Reduced Length of Hospitalization, Readmission and ED visit Rates: By providing complex care planning upon admission and proactive post-discharge support, the ICP model aims to lower length of patient hospitalization, hospital readmissions and unnecessary ED visits, reducing associated healthcare costs.
Improved Resource Efficiency: Effective discharge planning and case management alleviate strain on hospital resources, making care delivery more efficient.
Long-Term Cost Savings: This proactive approach to managing complex cases reduces long-term expenses and supports the sustainability of healthcare services.
Long-Term Cost Savings: This proactive approach to managing complex cases reduces long-term expenses and supports the sustainability of healthcare services.
Project Theme Information
In Canada, adults with multiple chronic conditions frequently use healthcare services and experience poor health outcomes, with hospital admissions consuming 30% of healthcare spending. Readmissions are both common and costly, especially for vulnerable populations, underscoring the need for new models that promote continuity of care and reduce reliance on hospitals. Patients often experience fragmented care, moving between specialists and wards without consistent support, leading to repeated admissions and inadequate post-discharge care. Additionally, adults with multiple chronic conditions account for 30% of healthcare spending, with frequent, costly readmissions underscoring the need for models that reduce hospital reliance and promote better care continuity. The Integrated Care Pathway (ICP) aims to improve case management and continuity of care for complex inpatients in the Calgary Zone, thereby reducing length of hospitalization, risk of mortality and morbidity post-discharge, and ED visits and readmissions to hospital.
The Integrated Care Pathway (ICP) model is a structured, team-based approach to discharge planning and post-discharge support. It focuses on high-risk patients, providing continuity of care, intensive case management, and tailored support to help patients transition from hospital to home while managing their chronic conditions more effectively. Patients are anchored to an Integrated Care Lead (ICL) who quarterbacks complex discharge planning, centralizes communication between hospital and home, plans and connects patients to relevant home and community supports, and follows patients for up to 90 days post-discharge. With the acute post-discharge period retaining the highest risk of return to the ED, readmission, or rapid decompensation, the ICL regularly phones the patient for the first 1-2 weeks to rapidly medically pivot if necessary. Additionally, a 24/7 line in collaboration with HealthLink is available for patients for up to 90 days.
The ICP model assigns a dedicated team member to support patients from their hospitalization through to post-discharge. This includes comprehensive discharge planning and community-based support for up to 90 days post-discharge, along with 24/7 phone support and personalized care plans documented in the electronic medical record (EMR) to ensure continuity.
Other Known Cases:
University Health Network in Toronto. University Health Network (UHN) adapted the successful pathway from this initiative to create the Integrated Care Pathway (ICP) (Appendix 1) in Toronto with the following services for >4000 individuals enrolled in the pathway since 2018:
1) Access to one care team: including connection to an Integrated Care lead during admission to hospital to create a complex transitional care plan that links with community services and primary care.
2) Access to one point of contact for support via a 24/7 phone line.
3) One shared electronic health record across acute care and home and community care.
4) Benefit from a flexible approach to funding that allows care to be personalized- this includes remote care monitoring and virtual care (where applicable).
5) Coordination of primary care, home and community-care and is supported by one funding source which follows the patient following discharge from hospital for up to 90 days (depending on patient need).
Get Involved
Contact Michelle
To collaborate or to help tell our story, please contact Michelle Grinman
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