INTEGRATED CARE
Patients’ needs are met through coordinated clinical and service-level planning and delivery across multiple professionals and organizations.
- Build strong foundational partnerships between home care and primary care.
- Optimize system resources and seamless navigation through care coordination.
- Facilitate joint planning, decision-making and open communication.
- Engage health and social care sectors with a focus on continuity for the client.
Choose the specific policy or program issue, review the possible tools and reports (title, date and precise), select the one that best suits your needs (click learn more for a detailed description) and click on the to access the on-line resource.
If you would like to share a resource for the Knowledge Centre – contact the CHCA Team at: chca@cdnhomecare.ca
Policy Issue: Cross-departmental collaboration
Program Issue:Identifying and engaging stakeholders
Stakeholders
Your Care, Your Say: Consumer and Community Engagement. Strategic Framework and Action Plan
Department of Health and Human Services, Government of Tasmania, 2009
This resource describes a process for engaging with a wide range of stakeholders to improve health and human services for everyone.
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Your Care, Your Say: Consumer and Community Engagement. Strategic Framework and Action Plan
- Description: Engagement at the individual, communities, services and system levels are critical components of both the framework and the action plan. The framework is based on four objectives: ensuring individuals can access the services they need; actively involving individuals in developing responsive, accessible and sustainable health and care services; making sure everyone (including staff) have the skill, knowledge and know-how to practice meaningful engagement; and developing trust and understanding in order to build healthier communities.
- Work originates from: Tasmania
- Resource can be applied to: health care sector
- Applicable to: Policy and program
Stakeholder Analysis (Stakeholder Matrix)
Tasmanian Government Department of Health and Human Services
This document can be used to obtain a clear understanding of key stakeholders for a particular project, and how they can be engaged.
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Stakeholder Analysis (Stakeholder Matrix)
- Description: The document illustrates how key stakeholders can be identified and plotted against two variables (e.g., stake in the outcomes and resources of the stakeholder, importance of the stakeholder and influence of the stakeholder) as part of developing a useful engagement plan for a project.
- Work originates from: Tasmania
- Resource can be applied to: multiple sectors
- Applicable to: Programming and service delivery
An Integrated Approach to Stakeholder Engagement
Carr, D., Howells, A., Chang, M., Hirji, N., & English, A. ehealth Strategy & Partnerships, Cancer Care Ontario. 2009.
This resource describes an integrated approach to engaging stakeholders in complex change management initiatives.
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An Integrated Approach to Stakeholder Engagement
Description: This resource contains information on how to communicate successfully with stakeholders by creating awareness, building support and making change real, based on the authors experience in conducting a large, complicated province wide change management initiative, i.e., the Wait Time Information System (WTIS) project.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Policy
Stakeholder Management and Change Management
Bourne, L. 2010
This resource discusses stakeholder management and change management and how both concepts are interrelated.
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Stakeholder Management and Change Management
- Description: This resource contains a discussion on stakeholder management and how it falls under overall organizational management and its importance in project management. It also compares stakeholder management to change management and how it should be incorporated at the change manager’s level.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Policy
Stakeholder Engagement Framework
Mississauga Halton Community Care Access Centre
This resource is a framework for engaging stakeholders.
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Stakeholder Engagement Framework
- Description: This resource contains information on why and when to involve stakeholders. It presents an overview of the stakeholder process including the foundations of engagement and five steps for engagement planning. It also provides templates and resources.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
Policy Issue: Multi-sector engagement / Long-term partnership models
Program Issue:Continuity of care
Continuity of Care
Home Care Tasks Checklist
AssistGuide Information Services, 2009
This checklist can be used to identify the types of personal care and household management tasks that individuals need assistance with.
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Home Care Tasks Checklist
- Description: The checklist provides a semi-structured approach to identify the types of tasks individuals need assistance with and how often the assistance is required.
- Work originates from: USA
- Resource can be applied to: home and community care sector
- Applicable to: Programming and service delivery
How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
Sevin, C.,Evdokimoff, M., Sobolewski, S., Taylor, J., Rutherford, P., & Coleman, E.A., Institute for Healthcare Improvement, 2013
This guide is intended to ensure that patients who are discharged from hospital are able to transition effectively into home health care.
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How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations
- Description: The guide describes three key areas that need to be addressed when transitioning individuals from hospital to home care. It identifies several steps that can be taken to address each of these areas in order to reduce rehospitalizations, and presents a number of approaches that can be used to determine the extent to which patient/client care is improved.
- Work originates from: USA
- Resource can be applied to: home and community care sector
- Applicable to: Programming and service delivery
Frameworks of Integrated Care for the Elderly: A Systematic Review
MacAdam, M. Canadian Policy Research Networks. 2008
This resource is a literature review on frameworks of integrated health care for seniors.
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Frameworks of Integrated Care for the Elderly: A Systematic Review
- Description: This resource contains the background, rationale and methods for the literature review. It also presents results on trials of integrated models of care, and reviews of programs of integrated health and social care for the elderly. It reports on the OECD Survey of Care Coordination and the European Union Survey of Integrated Care Approaches. Finally, it presents key frameworks of integrated care including the CARMEN Framework and the Hollander and Prince Framework.
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Policy
Integration: A New Direction for Canadian Health Care. A Report on the Health Provider Summit Process
Canadian Nurses Association. Canadian Medical Association. Health Action Lobby. 2013
This resource is the report of the health provider summit process whose focus is to transform the Canadian health care system.
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Integration: A New Direction for Canadian Health Care. A Report on the Health Provider Summit Process
- Description: This resource contains three parts, that is, taking action, outcomes and stakeholder engagement. It presents the three phases of the provider summit: the continuum of care, the continuity of care; and integrated care. Finally, it presents five foundations for integrated care: patient access, patient-centred care, informational continuity, management continuity and relational continuity.
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Policy
CMA Policy: Funding the Continuum of Care
Canadian Medical Association. 2010
This resource is the Canadian Medical Association (CMA) Policy on the funding of the continuum of care in Canada.
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CMA Policy: Funding the Continuum of Care
- Description: This resource contains a discussion of the history of continuing care and how health care has moved over time from institutions to the community. It presents the CMA’s guiding principles for funding the continuum of care and also discusses the elements of the system such as prevention and health promotion, pharmaceuticals and home care. Finally, it provides recommendations in each on how to move forward, for example in the home care section the recommendation is that patients actively participate in care and treatment plan.
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Policy
Organizing Healthcare Delivery Systems for Persons with Ongoing Care Needs and Their Families: A Best Practices Framework
Hollander, M.J., & Prince, M.J. Hollander Analytical Services Ltd. University of Victoria. 2007
This resource provides a best practices framework for organizing a healthcare delivery system for persons with ongoing care needs and their families.
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Organizing Healthcare Delivery Systems for Persons with Ongoing Care Needs and Their Families: A Best Practices Framework
- Description: This resource contains key challenges to care coordination and integration including differences in philosophy and regionalization. It presents a detailed list of types of community based services provided to type of population group (i.e., seniors, persons with disabilities, mental health and children with special needs). Best practices framework for organizing systems of continuing/community care services including: the philosophical and policy prerequisites; administrative and clinical best practices; and linkages with hospitals, primary healthcare and other social and human services.
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Policy and Program
Impact of PRISMA, A Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-Experimental Study
Hébert, R., Raîche, M., Dubois, M-F., Gueye, N.D., Dubuc, N., Tousignant, M., & The PRISMA Group. Universite de Sherbrooke. 2009
This resource is an evaluation of the impact of the PRISMA Model had on health, satisfaction, empowerment and service utilization for frail older adults using a quasi-experimental design.
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Impact of PRISMA, A Coordination-Type Integrated Service Delivery System for Frail Older People in Quebec (Canada): A Quasi-Experimental Study
- Description: This resource contains a study on the PRISMA model for frail older adults. Data was collected using bi-monthly telephone questionnaires and the level of disability in the participants was measured using the Functional Autonomy Measurement System. The findings were that the PRISMA model improves the efficacy of the health care system for frail older adults.
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Programming and service delivery
Policy Issue: Care transitions across multiple settings
Program Issue:Navigation between care transitions
Settings of Care & Transitions
Post Discharge Tool
National Patient Safety Foundation, 2015
The tool is designed to assist individuals who are getting out of hospital to follow their care plan and avoid being readmitted to hospital.
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Post Discharge Tool
- Description: The tool contains forms (which can serve as communication tools for family members and home care workers) for monitoring follow-up appointments, follow-up care, and post-discharge medications. It also contains a number of tips to help individuals understand their condition, reduce the possibility of being readmitted, and communicate with their health care provider(s).
- Work originates from: USA
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
TOC (Transitions of Care) Checklist
National Transitions of Care Coalition
This checklist is intended to enhance communication among health care providers, between care settings and between clinicians and clients/caregivers of patient assessments, care plans and other essential information.
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TOC (Transitions of Care) Checklist
- Description: The checklist can be used to communicate information regarding: physiological functioning; psychosocial functioning; cultural factors; health literacy and linguistic factors; financial factors; spiritual and religious functioning; physical and environmental safety; family and community support; medical issues; and continuity/coordination.
- Work originates from: USA
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
The Care Transitions Program®
Coleman, E., University of Colorado Denver, School of Medicine, 2006
This resource is intended to support patients and families and increase skills among healthcare providers.
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The Care Transitions Program®
- Description: This resource includes a four week program during which patients are supported by a Transitions Coach®. It also includes a short survey to assess the quality of care transitions, a medication discrepancy tool, a discharge preparation checklist and a tool to assess the contributions of family caregivers.
- Work originates from: USA
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
Integrated models of care delivery for the frail elderly: international perspectives
Beland, F., & Hollander, M.J. Gaceta Sanitaria. 2011
This resource is an international review of integrated systems of care for the frail elderly.
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Integrated models of care delivery for the frail elderly: international perspectives
- Description: This resource contains a literature review of integrated systems of care for the elderly. The full search found 2,505 documents which were narrowed down by independent reviewers using specific criteria for a total of 9 documents (e.g., there had to be a good description and it had to have been evaluated). It was found that there were two different kinds of models of integrated care for the frail elderly: 1) smaller, community based cooperative models focused on home and community care; and 2) large scale national/provincial/state model with a single administrative authority and budget and included both home and community care and residential services.
- Work originates from: International
- Resource can be applied to: home and community care sector
- Applicable to: Programming and service delivery
Interventions and Measurement Tools Related to Improving the Patient Experience through Transitions in Care: A Summary of Key Literature
Fancott, C. The Change Foundation. 2011
This resource is a summary of key literature on the patient experience through transitions in care.
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Interventions and Measurement Tools Related to Improving the Patient Experience through Transitions in Care: A Summary of Key Literature
- Description: This resource contains a literature review, evaluation strategies and tools, definitions, a conceptual framework, key findings and models of the patient experience through transitions in care.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Policy
Mapping the State of the Art: Integrating Care for Vulnerable Older Populations
Williams, P.A., Deber, R., Lum, J., et al. Canadian Research Network for Care in the Community. 2009
This resource presents the findings of a 2008 review of 47 models that integrate health and social care for older persons.
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Mapping the State of the Art: Integrating Care for Vulnerable Older Populations
- Description: This resource contains the purpose of the review and why integration is important. It presents the methodology and findings from the review of models of integrated care, which include different care settings. It presents six common and key design features including: targeting services to appropriate needs groups; flexible case management; flexible services; diversity of care settings; integrating funding; and integrating structures and institutions. Finally, it presents a table with key information on all 47 models.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Policy and program
Safety in Canadian Health Care Organizations: A Focus on Transitions in Care and Required Organizational Practices
Accreditation Canada. 2013
This resource is a discussion on safety in Canadian health care organizations.
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Safety in Canadian Health Care Organizations: A Focus on Transitions in Care and Required Organizational Practices
- Description: This resource contains information on the partnership between health care organizations and Accreditation Canada and describes the number of organizations in Canada that are accredited with them. It also contains information on care transition standards and required organizational practices, i.e., evidence based practices that mitigate risks, strengths and trends in safety as well as presents improvements and enhancements to safety. Finally, it present information on the 2012 compliance rates on a variety required organizational practices, from highest to lowest compliance.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
Policy Issue: Structured agreements and partnerships
Program Issue:Integrated care teams
Coordination & Collaboration
Collaborative Care: A Medical Liability Perspective
The Canadian Medical Protective Association
This resource discusses the medical and legal risks of collaborative care and proposes solutions to mitigate these risks.
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Collaborative Care: A Medical Liability Perspective
- Description: This resource defines collaborative care and discusses its benefits. It presents the current status of collaborative teams in Canada. It also discusses accountability and liability issues for policy makers and health professionals. It presents two models which address the above issues.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Policy
Making Way for Change: Transforming Home and Community Care for Ontarians. A White Paper
Ontario Association of Community Care Centres. 2014
This resource discusses complexities of Ontario’s home care system and how it can be improved by streamlining and strengthening it.
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Making Way for Change: Transforming Home and Community Care for Ontarians. A White Paper
- Description: This resource contains facts about the current system and makes a case for change. It provides barriers to transformation including the complex structure of the system and lack of funding stability. Furthermore, it argues that the legislative, regulatory and policy framework is outdated. Finally, it presents recommendations for change including adopting a flexible, adaptable home care service model and providing funding stability.
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Policy
Integrating Care for Seniors Living at Home
MacLeod, K.K. Policy Options. 2012
This resource contains a discussion on the key policy issue of integrating home care into the health care system to meet the changing needs of the Canadian population.
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Integrating Care for Seniors Living at Home
- Description: This resource contains a discussion on the challenges of home care delivery and the importance of accessing, coordinating and managing multiple services for seniors. It posits that more attention should be paid to integrated care as it’s a cost-effective method of delivering coordinated, accessible, and high quality care to seniors. It discusses the Ontario SMILE program, which seems to be a good example of an integrated care program.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Policy
A Survey of Leading Chronic Disease Management Programs: Are They Consistent with the Literature?
Wagner, E.H., Davis, C., Schaefer, J., Von Korff, M., & Austin, B. Managed Care Quarterly. 1999
This resource describes surveys and site visits of 72 expert-nominated innovative and effective chronic disease programs.
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A Survey of Leading Chronic Disease Management Programs: Are They Consistent with the Literature?
- Description: This resource contains data on the characteristics of programs and health systems in relation to chronic disease. 72 programs were identified by experts and then compared to a Model for Effective Chronic Illness Care. The model was found to be useful in describing the characteristics shared by success programs and could be used as a checklist for new programs or may provide a road map for organizations wanting to change their systems.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
Integrated Models of Primary Care and Mental Health & Substance Use Care in the Community: Literature Review and Guiding Document
Flexhaug, M., Noyes, S., & Phillips, R. British Columbia Ministry of Health. 2012
This resource is a review of models of integrated care that included primary care services for people with mental health and/or substance use needs in order to inform planning.
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Integrated Models of Primary Care and Mental Health & Substance Use Care in the Community: Literature Review and Guiding Document
- Description: This resource contains a literature review of themes that support integrating primary and mental health/substance use community care. In total, nine different types of collaborative models were found, from models that address mild to moderate needs (communication models) to models that address severe and complex needs (integrated team models). It also addresses subpopulations such as the elderly and children and how to make it work (e.g., using an interdisciplinary team approach and fostering relationships).
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
Policy Issue: Communication strategies
Program Issue:Effective communication
Communication
Evidence Boost: A Review of Research Highlighting How Patient Engagement Contributes to Improved Care
Baker, G.R. Institute of Health Policy, Management and Evaluation. University of Toronto. 2014
This resource is a summary of research on case studies of patient engagement for health system improvement in four countries.
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Evidence Boost: A Review of Research Highlighting How Patient Engagement Contributes to Improved Care
- Description: This resource contains strategies to improve patient care, barriers that prevent improvement, strategic responses, organizational factors that support successful patient engagement, key dynamics and key findings from case studies and interviews with key experts.
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Policy
Patient and Family Engagement. Involving People: The Path to Improvement
Judd, M. Canadian Foundation for Healthcare Improvement. 2015
This resource describes the Canadian Foundation for Healthcare Improvement’s involvement in patient engagement strategies and projects in Canada.
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Patient and Family Engagement. Involving People: The Path to Improvement
- Description: This resource contains information on the Canadian Foundation for Healthcare Improvement’s patient engagement projects and collaborations, a resource hub, webinar series, and ingredients to successful engagement
- Work originates from: Canada
- Resource can be applied to: home and community care sector
- Applicable to: Programming and service delivery
Putting Patients First: Patient-Centred Collaborative Care. A Discussion Paper
Canadian Medical Association 2007
This resource discusses the Canadian Medical Association principles on collaborative care.
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Putting Patients First: Patient-Centred Collaborative Care. A Discussion Paper
- Description: This resource contains the Canadian Medical Association view of collaborative care as well as the principles of collaborative care including clear communication.
- Work originates from: Canada
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery
Home Care Toolkit
Healthcare and Elder Law Programs (H.E.L.P.) Corporation, 2010
This toolkit is intended to assist older adults, family members and others in planning for and dealing with home care.
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Home Care Toolkit
- Description: The toolkit contains information and forms related to: determining a client’s needs; finding, interviewing and selecting home care workers; creating a written contract; creating and following both a care plan and a care log; tracking medications; tracking expenditures related to the client’s care; creating an inventory of the client’s belongings; supervising, communicating and problem solving with the home care worker; and meeting employment requirements.
- Work originates from: USA
- Resource can be applied to: home and community care sector
- Applicable to: Programming and service delivery
Always Use Teach-back! Training Toolkit
Unity Point Health, Picker Institute, Des Moines University & Health Literacy Iowa, 2015
The toolkit is designed to help all health care providers learn to use teach-back to support patients and families throughout the care continuum.
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Always Use Teach-back! Training Toolkit
- Description: This toolkit combines the use of plain language and teach-back to confirm understanding with coaching to new habits and adapting systems to promote consistent use of key practices. It contains: an introduction to using the toolkit; 10 elements of competence for using teach-back effectively; a 45 minute interactive teach-back learning module; and coaching tips and tools to help managers and supervisors empower staff to always use teach-back. Coaching tools include a Conviction and Confidence Scale as well as a Teach-back Observation Tool.
- Work originates from: USA
- Resource can be applied to: health care sector
- Applicable to: Programming and service delivery