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Reading: Using a Learning Health System Approach to Evaluate an Integrated Model of Care in East Toronto


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Using a Learning Health System Approach to Evaluate an Integrated Model of Care in East Toronto


Sara Shearkhani ,

East Toronto Health Partners, Canada, CA
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Mark Fam,

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Anne Wojtak,

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Walter Wodchis

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East Toronto Health Partners (ETHP) is implementing a new model of integrated care (IC).  ETHP is comprised of 50+ health and social organizations in East Toronto, with a leadership council consisting of patient/caregivers and six anchor organizations representing the continuum of care.

Short description

ETHP is co-creating an IC model in which hospital, primary care, community providers and patients and families work together as one coordinated team in order to improve population health, patient and provider experience, and value for money (Quadruple Aim).

Aim and theory of change

The aim is to create a learning health system within ETHP by embedding rapid cycles of evaluation to support learning, knowledge transfer, and decision making for scale and spread of this new model of care. To achieve this goal, a Developmental Evaluation (DE) is being implemented led by an embedded researcher. The evolution to having an embedded researcher is, itself, part of ETHP’s evaluation learning journey started in 2017.

Targeted population

The priority populations include seniors with chronic care needs and their caregivers, and individuals of all ages with mental health challenges and substance use issues. ETHP’s mandate is to expand the model’s scope and coverage to cover the entire population of East Toronto, over its first 3-5 year mandate.


Building on findings of The DE started in the fall of 2020 and is set up for 2 years.


In year 1 of DE and within 4 months, ETHP established an evaluation steering committee including two patient advisors to provide advice on the evaluation framework for the partnership, and ongoing evaluations of individual initiatives. To build capacity, ETHP held a series of evaluation workshops focusing on evaluation types, developing logic models, and measurement. Project level evaluations are being undertaken in to programs, Primary and Community Care Hubs and Winter Surge initiatives (each with multiple specific projects). A common evaluation template used across projects enabled the embedded researcher to guide teams toward a similar logical model structure, measures definition and reporting. Teams have started data collection and analyses, with reporting expected in March 2021.

Transfer-ability and sustainability

By embedding rapid cycles of evaluation, ETHP aims to support strategic expansion of the IC model across its entire population. The focus on building internal evaluation capacity and an evaluation community of practice ensures sustainability.

Conclusions; Discussions

Lessons learned: ETHP is using DE to create a more integrated system of care for residents and providers across East Toronto. In its early stages, DE focused on identifying the processes of change in collaboration with executives, providers, staff, and patients/caregivers, as well as building internal evaluation capacity for internal teams to engage in ongoing evaluation activities, creating a community of practice. Main finding regarding evaluation of ETHP IC model is that it is critical to a) measure the integrated way of working from different perspectives, b) closely monitor implementation and redefine evaluation plans to address the reality of working within an ever-changing and complex care setting, and c) to assess teams’ capacity and evaluation needs.

How to Cite: Shearkhani S, Fam M, Wojtak A, Wodchis W. Using a Learning Health System Approach to Evaluate an Integrated Model of Care in East Toronto. International Journal of Integrated Care. 2022;22(S1):65. DOI:
Published on 08 Apr 2022.


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