Abstract
Integrated care is most effective when the system is built around the patient, rather than requiring the patient to navigate the system. This was the guiding principle behind the Calgary Foothills Primary Care Network's case collaborative program, initiated over five years ago. Roughly 20% of Canadians experience mental illness or addiction issues annually, with 57% of those seeking professional mental health care consulting a family doctor first. Modern healthcare complexity demands provider collaboration yet lacks a structured framework for support.
Feedback from patients and families highlighted challenges in navigating numerous resources and coordinating care across multiple agencies. In response, the case collaborative initiative was established, bringing together doctors, healthcare professionals, schools, communities, and government services. This collaborative approach addresses the complex health, psychological, and social needs of patients. The model, co-designed by the Primary Care Network and community partners with input from patient advisors, aligns with best practices such as patient-centered care, team-based care, population-focused care, evidence-based and quality improvement.
The successful implementation of four case collaboratives has addressed 223 cases, focusing on concerns such as a lack of family resources, coordination of care, housing, financial issues, and social isolation. Evaluation results indicate that 85% of providers believe the model facilitated timely connection to resources, 91% believe it enhanced patients' quality of care, and 100% felt empowered to provide care. Patients reported feeling better supported, emphasizing the collaborative team's significant impact.
The strengthened relationships among providers have not only benefited patients directly involved but have created a ripple effect, improving overall service delivery in the community. Our presentation will emphasize the integration of primary health care with patients and families as active partners. We'll outline the transition from traditional primary health practices to an integrated community care model, focusing on the co-design of the case collaborative model, key principles, challenges, learnings, and enablers supporting its success. Our goal is to contribute to a primary care collaborative that leads to better health, care, and value.
Our future steps include enhancing patient engagement, transitioning to an inclusive model where families serve as primary referrers, and scaling the model provincially, nationally, and internationally.