Abstract
Background: Integrated healthcare delivery systems which meaningfully address patients’ needs as they transition between acute care and home/community supports can fulfil the Quintuple Aim, leading to improved experience and health outcomes. Mixed methods data rooted in cross-sectoral patient-centered outcomes can help direct continuous improvement and ensure sustainability of these integrated care systems. Two teams at the University Health Network (UHN) (Toronto, Ontario) and a working group in Calgary, (Alberta), Canada have developed an Integrated Care Program (ICP) as a collaborative learning health system (LHS). The ICP enrolls and links patients and their caregivers to home and community support, one point of contact, and a 24/7 phone support line, post-discharge.
As the program expanded from a post-surgical cohort to individuals with multimorbidity, complexity and frailty, our aim was to ensure our evaluation plan was feasible and sustainable for local, provincial and national spread and could help inform learning health systems. Qualitative findings via a Realist evaluation revealed the necessity for (a) a centralized health record system to enable continuous communication between hospital and home (b) increased resources (e.g., clinical personnel and expenditure) to support multimorbid, (socially) complex, and frail patients that are typical of medicine pathways (c) increased patient engagement in recovery plan to facilitate relationship building and trust as a means to improve clinical outcomes and (d) increased provider integration (i.e., family doctors) and buy-in to support program utilization and services offered.
We created program-level surveys to remedy low response rates to national patient experience surveys. We linked site-specific data to provincial administrative data in Ontario to allow for comparison with controls where healthcare utilization data outside the hospital is unavailable. Low or incomplete responses on language, gender, race and income equity and diversity measures upon hospital admission necessitated a manual chart review to build a machine learning model for more feasible capture as the program spreads. A major challenge in sustained implementation of integrated healthcare delivery systems is the paucity of meaningful and feasible evaluation metrics that address quality standards for care transitions and the Quintuple Aim, and can be used within a LHS for program refinement and scalability.
Audience: Health professionals, researchers, and policy-makers, healthcare administrators with experience or interest in integrated care models supporting acute care admissions. Patients and caregivers with experience navigating care transitions are also invited to attend to enrich the discussions.
Approach:
Part 1: 10 min. introduction + 40 min. presentation of results + 10 min discussion/question period.
Part 2: Applying evaluation plan to your integrated care implementation: 20 min. group work focused on challenges and solutions + 10 min summary by groups with reflections by panel of presenters.
Outcomes: During the workshop, a notetaker for each workshop group will document and summarize the discussions and key take-home messages, alongside unanswered questions. These notes will also help inform future knowledge translation through dissemination of key messaging to any participant who shares interest in receiving them.