The Care Integration Community is a dedicated space to collaborate on practices that integrate care across organizational, geographical, social and political boundaries to improve patient outcomes. This Community is a space to share resources & connect with others interested in improvements within this realm. (Note that since this is a public space, posting confidential information is not recommended). Browse our resources to see case studies, tools, and articles that might help generate some ideas for implementation within your organization. Share your thoughts and expertise, and ask questions to join the conversation – you can also upload additional resources here.

General information about communities of practice can be found below:

 
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Adherence to Clinical Practice Guidelines Improves Care for Patients at Ontario Shores

Ontario Shores Centre for Mental Health Sciences (Ontario Shores) is a public teaching hospital specializing in comprehensive mental health and addiction services for those with complex, serious and p...

Sharing Best Practices Through Online Communities of Practice: Global Alliance for Pre-Service Education (GAPS)

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Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms

Key Questions: What are the gaps in the healthcare system?...

CONNECT's Life Redesign Model™ - Client and Family Centred Care in Acquired Brain Injuries

Traumatic Brain Injury is the biggest disabler of Canadians under 45 years of age and an estimated 50,000 strokes occur in Canada each year with incidence rates on the rise in nearly every age group.&...

How Can Unnecessary Health Care Utilization be Eliminated?

 Identify and Utilize Evidence-based Best Practice Protocols and Guidelines for Diagnosis, Treatment and CareThere are a number of good sources for evidence-based recommendations that can be acce...

Transforming Patient Engagement: Health IT in the Patient Centered Medical Home

Key Questions: How can health information technology be used as an enabler for patient and family engagement? What kinds of structures need to be in place to support this?...

Seamless Transitions: Hospital to Home

Effective transition from acute care to community care is an essential element of high quality patient care and is a core business of hospitals and Community Care Access Centres (CCACs)....

Seamless Transitions: Hospital to Home Program Reduces Re-admissions & Enhances Patient Experience

There is a lack of shared understanding of patients’ needs to inform and execute a care plan that will give them confidence to leave the hospital....

Using a Supported Self-Directed Care Model to Assist At-Risk Informal Caregivers in Improving Toronto Seniors’ Well-Being

The family and friends of seniors living at home who informally provide care for them are valuable contributors to the viability of Canada’s healthcare system going forward....

Integrated Models of Primary Care and Mental Health & Substance Use Care in the Community: A Literature Review & Guiding Document

The work to develop this guiding document was overseen through a tripartite partnership between the Ministry of Health‘s Mental Health and Substance Use Branch, the Ministry of Children and Fami...

Evolving Models of Behavioral Health Integration

The new report provides an updated scan of the literature over a five-year period (2010 to 2015), identifying changes and gaps in the evidence since publication of the 2010 report....

Integrating Mental Health Services into Primary Health Care

Primary health care is about providing 'essential health care' which is universally accessible to individuals and families in the community and provided as close as possible to where people li...

Improving Patient Transitions with Nurse Oversight via Care at Hand mHealth: Elder Services of the Merrimack Valley

ESMV wanted to provide their non-clinically trained health coaches with nurse oversight to deliver better quality clinical support to patients transitioning from the hospital to the home environment....

What it Takes to Make Integrated Care Work

Key Questions: How can integrated care be effectively implemented?...

Geriatric Emergency Management (GEM): A Program Development Toolkit

Key Questions: How can Geriatric Emergency Management be improved?...

Volunteers Enabling Seniors to Live at Home: Home for Life, South Georgian Bay

The aging population often faces issues of isolation and loneliness when they enter Long-Term Care (LTC) facilities....

The Patient-Centered Medical Home Multidisciplinary Intervention May Reduce Readmissions Among Older Adults

Older adults are a vulnerable population during transitions of care. Nearly one-fifth of hospitalized Medicare beneficiaries in Michigan are re-hospitalized within 30 days....

Patient and Family-Centered Care Organizational Self-Assessment Tool

This self-assessment tool allows organizations to understand the elements of patient- and family-centered care to assess their current position against best practice.

Sentara Healthcare: A case study series on disruptive innovation within integrated health systems

Disruptive innovations in health care have the potential to decrease costs while improving both the quality and accessibility of care....

Brigham and Women's Hospital Nursing Innovation Units Reduce LOS for Orthopedic Surgical Patients via Discharge Bundle

The Brigham and Women's Hospital Innovation Units were identified in September 2011. One of the innovation units’ areas of focus was improved discharge of the patient.

Person-Centered Care: A Definition and Essential Elements

Improving healthcare safety, quality, and coordination, as well as quality of life, are important aims of caring for older adults with multiple chronic conditions and/or functional limitations....

Adding a Measure of Patient Self-Management Capability to Risk Assessment Can Improve Prediction of High Costs

Patients with the knowledge, skills, and confidence needed to manage their health conditions are sometimes referred to as “activated.” Health care systems can use patient activation scores...

Connecting Northern and Eastern Ontario Community and Hospital Care Information Systems to Better Integrate Care

There is a need for technology solutions to more effectively integrate shared data between hospitals and primary care....

Emerging Idea: Expanding Paramedicine in the Community (EPIC) Pilot Designed to Reduce ED Visits

Pressures on emergency departments globaly are increasing due to factors such as population aging and chronic disease and comorbidity....

The Champlain Geriatric Emergency Management Plus (GEM+) Program Improves Outcomes & Reduces Hospital Utilization

Many people enter and access the healthcare system through the emergency department (ED). This can lead to overcrowding combined with a high stress environment....

Customer Orientation — The Executive Walkthrough

This tool can help leadership see the organization(s) through a customer’s eyes. It is helpful to perform this exercise for both your and your partner’s organization....

E-Notification Add-On to Hospital Report Manager Improves Coordination of Care

Healthcare delivery, particularly for complex patients, requires communication and coordinated care that can traverse multiple departments and providers....

Telehomecare in Ontario Improves Chronic Disease Management

Chronic diseases are a major cause of death and disability worldwide....

The SAFER patient flow bundle

The SAFER patient flow bundle is a practical tool to reduce delays for patients in adult inpatient wards (excluding maternity)....

Working With Patients and Families as Advisors

The Guide to Patient and Family Engagement in Hospital Quality and Safety is a resource to help hospitals develop effective partnerships with patients and family members with the ultimate goal of impr...

How Can Telehealth Help in the Provision of Integrated Care?

The quest for more integrated care is not itself new, but new opportunities for effective realisation have emerged quite recently....

Nurse Bedside Shift Report

Nurse shift changes require the successful transfer of information between nurses to prevent adverse events and medical errors....

Integration: A New Direction for Canadian Health Care

When CNA and CMA began discussing how to help Canadians secure the best health and health care in the world by 2025, they concluded that a functionally integrated health system along the full continuu...

Discharging Elders from ED to Community: What You Need to Know?

This project allowed for the summarizing of all evidence-based post-ED community services that help restore functional ability and prevent frailty from the international literature and generate a tool...

Making Integrated Out-of-Hospital Care a Reality

This paper provides a set of principles to lay the foundations for delivering effective integrated out-of-hospital care, each underpinned by a range of drivers and enablers....

A Framework for Integration of Community and Clinical Care to Improve the Delivery of Clinical Preventive Services Among Older Adults

This report proposes an overarching framework – based on the principles of current evidence based models – to integrate community and clinical care for the delivery of a core set of preven...

Communicating to Improve Quality

Communication between the patient, family, and clinicians is a critical component of high-quality, safe care and the foundation of partnerships between the patient, family, and clinicians. Commun...

Guide to Patient and Family Engagement in Hospital Quality and Safety

The Guide to Patient and Family Engagement in Hospital Quality and Safety is a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safe...

What is Integrated Care?

‘Integrated care’ is a term that reflects a concern to improve patient experience and achieve greater efficiency and value from health delivery systems....

What is Colleaga?

Colleaga is a voluntary non-profit organization whose members share the common belief that when we join together, we are stronger and wiser and can achieve significantly greater impact.Reaching a...

Behavioral Health Integration Capacity Assessment (BHICA)

Key Questions: What are better approaches to integration? Who will this help?...

Boston Children's Hospital DisCO Application to Keep in Touch with Families After Discharge

After patients are discharged from the hospital, patients and their families generally experience challenges with the transitions of care....

How-to Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations

Key Questions: How can transitions from the hospital to the clinical office practice be improved?...

How Can Healthcare Be Better Integrated Across Boundaries?

 Use Technology as a Means to Communicate with Other ProvidersEliminating silos so that providers can share information and resources is critical to smooth patient transitions across boundaries (...

Physician Engagement in Community-based Care Coordination (CCC)

Key Questions: How can physicians be effectively engaged in establishing a community-based care coordination (CCC) program?...

Email Templates for Patient and Caregiver Engagement

Key Questions: How can my organization go about soliciting patient and caregiver engagement?...

Care Transitions from Hospital to Home: IDEAL Discharge Planning

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Improving the Integration of Mental Health Services in Primary Health Care at the Macro Level

Typically, individuals requiring mental health care for most moderate/mild cases are supported in primary health care (PHC), though specialist care in secondary and tertiary settings is required for m...

Knowledge Mobilization Plan

This toolkit can help you think through different ways to mobilize knowledge and create a solid plan for moving ahead....

Using Internet-based Cognitive Behavioural Therapy at Scarborough Hospital to Deliver More Patient-Focused Care

Across Canada, there are long wait times for necessary Cognitive Behavioural Therapy (CBT) services. CBT is considered the “gold standard” for the treatment of depression and anxiety....

Clinically Informed Consensus Guidelines for Improved Integration of Primary Care and Mental Health Services in California

The following clinical guidelines were developed to address a common and growing problem in contemporary health care practice: how can people’s coexisting general health and mental health care n...

HealthPartners: A case study series on disruptive innovations within integrated health systems

Disruptive innovations in health care have the potential to decrease costs while improving both the quality and accessibility of care....

How-to Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations

Key Questions: How can transitions from the hospital to skilled nursing facilities be improved?...

Improve Decision Making Involving Frail Elderly and Caregivers on Location of Care

Key Questions: How can decision making regarding Location of Care (LOC) for frail seniors and their caregivers be improved? This tool provides a guide for improving the decision-making process in...

Integrated Comprehensive Care at St. Joseph's Health System Improves Coordination and Reduces Costs

Population aging combined with increasing levels of chronic disease and comorbidity puts pressure on health systems to deliver care more efficiently....

Partnering with Patients and Families to Design a Patient and Family Centred Health Care System

This report is based on the deliberations that took place at a one-day invitational meeting was convened by the Institute for Family-Centered Care (IFCC) in collaboration with the Institute for Health...

Patient-Centered Primary Care Collaborative a Key Solution for Healthcare Fragmentation: Medical Home Network

The health care system in Chicago is provided by disparate entities with little to no communication between them....

Introducing a Patient Flow Bundle to Improve Discharge at Ipswich Hospital

Across the UK there are wide variations in length of stay, even for patients with similar conditions....

Partners HealthCare Improves Quality of Care While Slowing Cost Growth

Partners HealthCare is an Accountable Care Organization (ACO) which are groups of doctors and other health care providers who work together to provide high quality care for their patients....

Integrated Assessment Record Enabled by Orion Health Allows Community Care Sector to Access Patient Data: Ontario

As the body in charge of health system planning for the Chatham-Kent, Sarnia/Lambton, Windsor/Essex regions, the Erie St....

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care?

Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics. This brief examines healt...

Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences

Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients—those who use the most health care services and account for a dispr...

Primary Health Care Patient Experience Survey Toolkit

The Patient Experience Survey Toolkit is a practical guide for surveying patients in primary care practices, public and primary health care services, or chronic disease management programs....

Paramedic Referral Toolkit

The Paramedic Referral process was conceived and developed to directly support Ontario’s Action Plan for Health Care....

COMPASS Primary Health and Behavioral Health™

The COMPASS-Primary Health and Behavioral Health™ (COMPASS-PH/BH) is a continuous quality improvement tool for clinics and treatment programs, whether working in their own integration process or...

The Administrative Readiness Tool (ART)

The ART is designed to help you assess and improve the core administrative processes needed most to support primary and behavioral health care integration....

One Client, One Team™: Transforming Integration at the Point of Care in the Toronto Central CCAC

Demographic and fiscal pressures are motivators for change in health systems. Ontario is experiencing a demographic shift, whereby the number of seniors is increasing exponentially....

Disruptive Innovation in Integrated Care Delivery Systems

Disruptive innovations in health care have the potential to decrease costs while improving both the quality and accessibility of care....

Gap Analysis: Patient and Family Engagement

Effective patient and family engagement is dependent on structures and processes....

Improving Chronic Illness Care through Integrated Health Service Delivery Networks

This document examines the linkages between the chronic care models and the Integrated Health Services Network (IHSDN) approach....

Ensuring a more equitable healthcare system: Addressing the needs of Canada’s frail elderly

To improve care for the frail elderly, we need to break down traditional silos that focus on single diseases and silos of local and regional healthcare systems and settings....

All Together Now: A Conceptual Exploration of Integrated Care

If health systems are going to tackle the challenges they are facing, for example, growing and aging populations and an increasing burden of chronic disease, new ways of connecting services and servic...

Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness

Trauma Centers, Hospitals, and Healthcare Systems face multiple challenges daily in addition to the growing list of man-made and natural threats....

Advancing Integrated Care: Cross-sector perspectives from Ontario’s health system

This report highlights change ideas and quality improvement activities that promote integrated care and, by extension, improved patient experiences....

The Evidence Base for Integrated Care

This concern has been about fractures in systems and delivery that allow individuals to ‘fall through the gaps’ in care – e.g., primary/secondary care, health/social care, mental/phy...

ISAR: A Screening Tool for Seniors in the Emergency Department at Increased Risk of Adverse Outcomes

The Identification of Seniors at Risk (ISAR) tool has been developed for use in the emergency department....

Taking Care of Myself: A Guide for When I Leave the Hospital

When a patient leaves the hospital, there are a lot of things they will need to do to take care of themselves....

Order Sets in Healthcare: An Evidence-based Analysis

This study was prepared for OHTAC by the Healthcare Human Factors Team based at the Centre for Global eHealth Innovation at the University Health Network, Toronto....

Clinical Best Practice Guidelines: Care Transitions

This nursing best practice guideline is a comprehensive document providing resources for evidence-based nursing practice and should be considered a tool, or template, intended to enhance decision maki...