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Conference Abstracts

Building on evidence-based models to accelerate the delivery of integrated care: The journey to date for the University Health Network, Toronto, Canada


Shiran Isaacksz

University Health Network, CA
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University Health Network (UHN), Canada's largest research and education hospital, implemented a patient-led integrated care program in June of 2019. Leveraging an evidence-based model developed by St. Joseph’s Health System (SJHS) the rollout was completed in four months and is already improving care for hundreds of surgical patients. At the same time new care pathways have been initiated to address the needs of both medicine and high-need patient populations.

Success of this program was in the ability to partner and co-design with patients, clinicians and other partners across the care continuum. Through this presentation, find out how UHN was able to accelerate delivery in Toronto, Canada’s largest urban centre. 

Practice Change Implemented

Co-designed by patients and providers, the surgical integrated care experience begins at the decision to operate, and supports patients throughout their acute surgical journey and recovery at home. 

Tackling UHN’s most common patient and caregiver complaints, the program includes;

•           One care team with one primary point of contact

•           One 24/7 phone line available to patients/caregivers

•           One shared digital health record

•           One integrated fund that covers both in-hospital and homecare services

Aim & Theory of Change

Addressing the quadruple aim, the program looks to improve the care experience, clinician satisfaction, quality outcomes and population health, which includes decreasing length of stay and reducing unnecessary readmissions and emergency department visits.

Critical to the success of this program was the focus on having patient partners and clinical champions prioritize the biggest needs to help quickly break through barriers to improve the care experience.

Targeted Population & Stakeholders

The integrated delivery team included patient/caregiver partners, acute and home & community care providers, finance and data resources, as well as government. As a patient led-program the team not only engaged patients directly in the program but also leveraged patient insights and ideas from several partners including local organizations and regional government bodies.

This program began in thoracic surgery and then expanded to additional surgical, medicine, and high-need patient care pathways.


The program was implemented over a four-month period from February – June, 2019.


The focus on patient identified priorities and learnings from an evidence-based model was critical to the speed of delivery. Other innovative tactics to accelerate implementation included creating guiding principles to ensure the patient experience drove decision-making; working to create a shared vision; having the appropriate clinical expertise; and investing in backbone support to support the change.

Early feedback indicates improved transitions and continuity of care, better communication and collaboration, a reduction in acute length of stay, readmissions, and emergency department visits.

Sustainability/Transferability & Conclusions

Looking towards the future, the program plans to advance the impact it has made through continuing implementation into new pathways, and creating an integrated care collaborative to share learnings and inspire others in their integrated care journey. 

How to Cite: Isaacksz S. Building on evidence-based models to accelerate the delivery of integrated care: The journey to date for the University Health Network, Toronto, Canada. International Journal of Integrated Care. 2021;21(S1):20. DOI:
Published on 01 Sep 2021.


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