Welcome to the Integrated Care Program

UHN's Integrated Care Program is changing the way care is delivered and experienced in Ontario and beyond.

This program supports a number of models that wrap care around our patients and makes it easier to communicate and coordinate care plans. Through this program, patients have:

• One point of contact
• One record for the care team to collaborate
• One support line available 24/7

Critical to the patient experience is the connection with an Integrated Care (IC) Lead whose role is to bring all care providers (e.g., hospital, homecare, primary care, etc.) together and ensure continuity of care, including helping patients get home as soon as possible and stay there.

In other words, IC removes the barriers and burdens associated with navigating and coordinating care for patients, and creates much-needed capacity via:

• Patient education and self-management
• Delivering more advanced care at home
• Decreasing length of stay
• Avoid unnecessary readmission and visits to hospitals

This in turn addresses the surgical and clinical care backlog, reduces hallway health care, and provides opportunities to modernize home and community care in a scalable and sustainable way.

To put it simply, the Integrated Care model frees up beds, clinician time, and keeps patients, as much as possible, at home and in their communities.

Our approach is led by patients and what they want, follows international integrated care best practices, and will continue to be designed by patients to support the following:

One team

Care
Coordination

One consistent care team with a primary point of contact

One Digital Record

Communication &
Continuity of Care

One story to tell, enabled by a shared digital record

One Number to Call

Easy &
Timely Access

One 24/7 phone line available to patients and caregivers

One Integrated Fund

Customizable
Care

One integrated fund to allow for flexibility for patients when and where needed

 

Focus on patient & caregiver needs.

 

Support care provider satisfaction & quality of work life.

 

Care model as driver of the integrated funding model.

 

Co-design and commitment to meet key metrics.

Integrated Care
Guiding Principles

 

Digitally enabling connected care.

 

Ensure sustainability and scalability.

 

Provide equitable care.

 

Shared accountability & transparency.

Creating a New Standard of Care

The success of the IC Program stems from UHN's investment in people and systems. We want an integrated care experience to be the standard of care for all individuals. Through partnerships, we bring together programs, providers and services to create new models of care. Each model of care is rooted in providing safe and high-quality care using proven protocols, while responding to the unique needs of each patient's medical and personal circumstances.

At UHN alone, we currently support thousands of patients annually with our growing list of IC pathways:

• Surgery (Cardiovascular, Orthopedic, Thoracic, Vascular)
• Medicine (CHF, COPD or COVID+ diagnosis)
• Transplant (Liver)
• Emergency Department (Respiratory Conditions, CHF and COPD)

We are expanding rapidly across UHN in FY 2023/24 and FY 2024/25 and work in partnership with Ontario Health (OH) Toronto Region, VHA Home HealthCare and partners, and other service providers and stakeholders across the GTA.

In addition to our efforts to support patients seeking care at UHN, we are also leading efforts beyond our walls to advance the ability for individuals in Ontario and beyond to benefit from an integrated care experience. Early efforts are already being leveraged across the Toronto region in leading demonstration projects for CHF and Diabetes as well as in addressing population health needs for older adults through our work with the NORC Innovation Centre. These efforts are being delivered and spread more broadly by our UHN Connected Care team.

For more information, please email integratedcare@uhn.ca.