From silos to shared care: cross case learnings on digitally enabled collaboration in integrated care

Background:Across Canada, teams delivering health, social, and community care continue to rely on care plans that exist either on paper or within siloed electronic medical record (EMR) systems. These plans are often fragmented, quickly outdated, and rarely include the patient or family. Coordination depends on phone calls, emails, and faxed updates that are inefficient, duplicative, and produce no usable data for improvement.

 

To strengthen continuity, transparency, and shared accountability, integrated care programs are adopting digitally enabled, distributed models of collaboration. This approach connects patients, caregivers, and providers around a single, shared, and dynamic plan of care that transcends geography and organizational boundaries.

 

Approach: This abstract presents cross case learning from more than a dozen integrated care initiatives, where health, social, and community partners adopted a purpose built digital platform to support real time communication, shared care planning, and patient participation. Programs included Hospital to Home (CIHR funded Digital Bridge to Home and bundled care initiatives), Integrated Palliative Care, Homelessness and Addictions care, Preventative Care, and Patient Navigation.

 

Each implementation was co designed with patients, caregivers, and frontline providers to align with workflows and lived experience. Shared dashboards were created to be signal not noise, showing the right information to the right people at the right time. Implementation followed Plan Do Study Act cycles to support continuous improvement, local adaptation, and system wide learning about what enables distributed integration in practice.

 

Results: Across all initiatives, digital shared care planning proved a practical enabler of collaboration among organizations that previously worked in isolation.

Key learnings

• Cross sector partnerships drove integration by aligning health, community, and social care partners around shared goals and accountability.
• Teams developed new workflows and communication habits, strengthening both relational and operational integration.
• Patients and families could view and contribute to their plans, improving understanding, confidence, and participation in care.
• Digital tools revealed variations in workflow and communication, allowing teams to identify and address practice issues.

 

Challenges and reflections

• Some teams were hesitant to include patients and families, even with evidence that engagement improves outcomes and efficiency.
• Providers sometimes projected their own discomfort with technology onto patients, though most were motivated and capable once invited.
• Many initiatives began without full integration, starting small to learn what information, workflows, and relationships added the most value.
• Providers experienced tool fatigue, overlooking that fragmented communication already existed through phone, email, and fax.

 

Implications: Digitally enabled shared care planning addresses informational and relational fragmentation, whether caused by paper based systems or disconnected EMRs, by creating shared visibility, accountability, and trust. While these tools cannot overcome policy or structural barriers, they provide a foundation for collaboration and learning across organizations.

These learnings are transferable to other technology enabled collaboration efforts internationally, particularly where teams seek to align around the person rather than their own organization. Future priorities include advancing interoperability, improving digital literacy among care teams, and scaling distributed shared care planning to promote equity, sustainability, and connectedness across diverse settings.