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Paving a Road Map for Integrated Care Evaluation in Canada: A Mixed Methods Evaluation for Patients With Complex Care Needs in Ontario and Alberta
Sponsor study identifier
Secondary identifiers
OTHER · THINC Implementation Science Team Grants, CIHR
interventional
2,000
1 country
1
Study Start
May 1, 2025
Estimated (date passed)This estimate has passed. The registry has not confirmed an actual date for this milestone.
Primary Completion
December 1, 2028
EstimatedPlanned date reported by the registry; this milestone is not confirmed as achieved.
Study Completion
December 31, 2028
EstimatedPlanned date reported by the registry; this milestone is not confirmed as achieved.
The Integrated Care Pathway (ICP) model can reduce hospital readmissions and emergency department (ED) visits while improving continuity of care. This model was first developed at the University Health Network in Toronto, Ontario, and has been adapted for patients at high risk of readmission and with medical/social vulnerability admitted to general medical units in the hospitals in Calgary, Alberta. The study will evaluate the ongoing adaption and implementation of the ICP model in Calgary. ICP patients will receive the following tenets of care:
Registry-reported information. Elapsed time and enrollment totals alone do not measure study progress or recruitment pace.
December 31, 2028
EstimatedPlanned date reported by the registry; this milestone is not confirmed as achieved.
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Some registry-reported names shown below are not yet linked in this graph.
Dates and qualifiers reported by the registry. Estimated dates do not confirm that a milestone has occurred.
November 5, 2024
Actual (reported)November 7, 2024
Actual (reported)May 1, 2025
Estimated (date passed)This estimate has passed. The registry has not confirmed an actual date for this milestone.
December 1, 2028
EstimatedPlanned date reported by the registry; this milestone is not confirmed as achieved.
December 31, 2028
EstimatedPlanned date reported by the registry; this milestone is not confirmed as achieved.
Patient experience
Proportion of patients reporting a positive experience up to three months following discharge from an acute care hospital, as defined by having the following top box (positive) responses to seven patient experience questions from the Canadian Institute for Health Information (CIHI) Canadian Patient Experience Survey on Inpatient Care (CPES-IC) , a standardized and validated survey sent out by all hospitals in English and/or French (see Appendix for all questions). Response options include ordinal frequencies or binary responses to questions focused on communication and care coordination (e.g., "During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help needed when you left hospital?"). The choice of top-box response to patient experience survey questions is being used to align with Canadian benchmarking and for comparison with HCAHPS patient experience survey questions for international representation ,.
From enrollment to 90 days post-discharge
Re-admission
up to 3 months after discharge
Quintuple Aim - a conceptual framework for evaluating quality of healthcare services developed by the Institute of Healthcare Improvement for evaluating new health programs
minimum 6 months post-implementation of ICP at all sites
Enrolled patients in the ICP will then undergo more assessment by the Integrated Care Lead to develop a preliminary inventory of their needs for transitioning back to their health home. Patients will then be assigned an Integrated Care Lead with expertise in managing their particular needs. This will result in the development of a complex care plan that is co-designed with a patient's acute and community care team (eg: primary care, home care, community services, hospital medical team etc). This plan will be documented in Connect Care and incorporated into the discharge summary at the time of hospital discharge. (see Appendix 2) Calgary Zone Integrated Care Program will then provide: * Continuity of care with the assigned ICP team member(s) throughout their hospitalization and connection with community resources and services in the process of complex discharge planning. * Efficient use of healthcare resources by reducing duplication of services and systematically screening for unmet
Complex care plan facilitated by the integrated care lead with 90 day follow-up, 24/7 phone support and connection with resources and services
Registry-reported names are shown in full. Names without a link have not yet been matched to a Syfrah profile.
University of Calgary
Calgary, Alberta, T2V 5A8, Canada
Wandersman A, Duffy J, Flaspohler P, Noonan R, Lubell K, Stillman L, Blachman M, Dunville R, Saul J. Bridging the gap between prevention research and practice: the interactive systems framework for dissemination and implementation. Am J Community Psychol. 2008 Jun;41(3-4):171-81. doi: 10.1007/s10464-008-9174-z.
Nundy S, Cooper LA, Mate KS. The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity. JAMA. 2022 Feb 8;327(6):521-522. doi: 10.1001/jama.2021.25181. No abstract available.
Michelle Grinman, MD FRCPC MPH
University of Calgary
First Submitted
November 5, 2024
First Posted
November 7, 2024
Study Start
May 1, 2025
Estimated (date passed)This estimate has passed. The registry has not confirmed an actual date for this milestone.
Primary Completion
December 1, 2028
EstimatedContact the study team to confirm eligibility.
Meyers DC, Durlak JA, Wandersman A. The quality implementation framework: a synthesis of critical steps in the implementation process. Am J Community Psychol. 2012 Dec;50(3-4):462-80. doi: 10.1007/s10464-012-9522-x.
Steele Gray C, Zonneveld N, Breton M, Wankah P, Shaw J, Anderson GM, Wodchis WP. Comparing International Models of Integrated Care: How Can We Learn Across Borders? Int J Integr Care. 2020 Apr 1;20(1):14. doi: 10.5334/ijic.5413.
Kiran T, Wells D, Okrainec K, Kennedy C, Devotta K, Mabaya G, Phillips L, Lang A, O'Campo P. Patient and caregiver experience in the transition from hospital to home - brainstorming results from group concept mapping: a patient-oriented study. CMAJ Open. 2020 Mar 2;8(1):E121-E133. doi: 10.9778/cmajo.20190009. Print 2020 Jan-Mar.
Hunting G, Shahid N, Sahakyan Y, Fan I, Moneypenny CR, Stanimirovic A, North T, Petrosyan Y, Krahn MD, Rac VE. A multi-level qualitative analysis of Telehomecare in Ontario: challenges and opportunities. BMC Health Serv Res. 2015 Dec 9;15:544. doi: 10.1186/s12913-015-1196-2.
Hahn-Goldberg S, Huynh T, Chaput A, Krahn M, Rac V, Tomlinson G, Matelski J, Abrams H, Bell C, Madho C, Ferguson C, Turcotte A, Free C, Hogan S, Nicholas B, Oldershaw B, Okrainec K. Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: a mixed methods evaluation. BMC Health Serv Res. 2021 Apr 17;21(1):361. doi: 10.1186/s12913-021-06374-8.
Isaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients' perception of care and measures of hospital quality and safety. Health Serv Res. 2010 Aug;45(4):1024-40. doi: 10.1111/j.1475-6773.2010.01122.x. Epub 2010 May 28.
Griffiths S, Stephen G, Kiran T, Okrainec K. "She knows me best": a qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure. BMC Fam Pract. 2021 Sep 7;22(1):176. doi: 10.1186/s12875-021-01524-7.
Okrainec K, Chaput A, Rac VE, Tomlinson G, Matelski J, Robson M, Troup A, Krahn M, Hahn-Goldberg S. Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals. PLoS One. 2022 Oct 4;17(10):e0268418. doi: 10.1371/journal.pone.0268418. eCollection 2022.
Okrainec K, Hahn-Goldberg S, Abrams H, Bell CM, Soong C, Hart M, Shea B, Schmidt S, Troup A, Jeffs L. Patients' and caregivers' perspectives on factors that influence understanding of and adherence to hospital discharge instructions: a qualitative study. CMAJ Open. 2019 Jul 18;7(3):E478-E483. doi: 10.9778/cmajo.20180208. Print 2019 Jul-Sep.
Planned date reported by the registry; this milestone is not confirmed as achieved.
Study Completion
December 31, 2028
EstimatedPlanned date reported by the registry; this milestone is not confirmed as achieved.
Last Updated
March 28, 2025
Record last verified: 2025-03
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