Integrated Care: A Person-Centered and Population Health Strategy for the COVID-19 Pandemic Recovery and Beyond

Ayodele Odutayo; Kevin Smith; Carolyn Gosse; Melissa Chang; Shiran Isaacksz; Christopher T. Chan

doi:10.5334/ijic.7536

Figures & Tables

Table 1

Case Study of the University Health Network Health Integration Program.

PATIENT ACUITY	SERVICE PROVISION	UHN SPECIFIC PROGRAMS DURING THE COVID-19 PANDEMIC
Highly Complex Patients	Case Management	Information-Sharing on Admission Bi-directional and timely information sharing amongst primary care and home and community care providers, relevant specialists with admitting team. Transitions of Care: A named health care professional is responsible for timely transition planning, coordination, and communication. Written transition plan, developed by and agreed upon in partnership with patients and circle of care shared within 48 hrs of discharge. Circle of care involved in planning and developing a written transition plan. Follow-up medical care with their primary care provider and/or a medical specialist is coordinated and booked before leaving. People with no primary care provider are provided with assistance to find one. Patient, Family, and Caregiver Education, Training, and Support: Information and support provided to manage their health care needs; education and training offered to manage at home, including guidance on community-based resources, medications, and medical equipment. Assess for the type, amount, and appropriate timing of home care and community support services are needed (including caregivers.) When needed, services are arranged before leaving and in place upon return home.
High Risk Patient	Acute Illness Management	Services oriented around information sharing on admission, transitions of care and patient, family and caregiver education, training and support Eligibility for General Internal Medicine Integrated Care Pathway Assessment and suitability for management at home Discharged home with 3 consecutive nursing visits post-discharge Ongoing monitoring with as needed visits for up to 2 weeks
Stable Chronic Disease	Disease Management	COVID-19 Connected Virtual Care Clinic Nurse led virtual care clinic for assessment and managing symptoms of COVID-19 for patients with stable chronic disease (e.g. transplant recipients) Distribution of pulse oximeters to facilitate home monitoring
Population Wide Prevention	Promotion and Prevention	Coordination of Primary and Secondary Prevention Programs Centralized prescription of monoclonal antibodies to prevent progressive to severe SARS-CoV-2 pneumonia Creation of vaccine clinics in line with Provincial mandates

[i] This table leverages the Kaiser Permanente Pyramid of Care as well as the Health Quality Ontario Hospital to Home Quality Standard to demonstrate how health care integration at the University Health network achieves the dual goals of person-centred care while improving population health.

Integrated Care: A Person-Centered and Population Health Strategy for the COVID-19 Pandemic Recovery and Beyond

Figures & Tables

Table 1

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