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Reading: Learnings from the field – An Integrated model of care for Hip and Knee Bundle Patients at UHN


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Conference Abstracts

Learnings from the field – An Integrated model of care for Hip and Knee Bundle Patients at UHN


Marsha Alvares ,

University Health Network - Toronto Western Hospital, CA
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Samra Mian-Valiante,

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Silvi Groe,

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Christian Veillette

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The Ontario Ministry of Health announced new Integrated Funding Models for Hip and Knee replacement surgery in 2018, providing a single payment covering the spectrum of care required for an individual health issue. Aim was to promote greater integration in health care delivery, drive high-quality efficient care, and improve patient outcomes and experience.

The Schroeder Arthritis Institute at University Health Network (UHN) developed an integrated care pathway that optimized patient transitions home after total joint replacement (TJR) based on best practice guidelines and enabled by large-scale change management, technology and value-based partnerships with a focus on patient engagement and collaboration.

Aims Objectives Theory or Methods

Value-based bundle funding models require innovation in care delivery to provide quality, evidence-based care across the care episode, improving efficiencies while maintaining strong clinical outcomes and patient satisfaction. Our existing pathways were challenged with inconsistent application of evidence-based guidelines and lack of patient representation in co-design and outcome measurement.

Our objective was to develop an integrated model at UHN utilizing existing partnerships to optimize the patient and caregiver experience, coordinate care in collaboration with the patient and their families to empower them and support transition home, identifying opportunities for efficiencies in care delivery that aligned with best practice.

Highlights or Results or Key Findings

Our integrated pathway began in April 2019 with 1287 TJR patients. Updated surgical guides, videos and resources facilitated patient empowerment and preparedness, early acute mobilization and warm handoffs to post-acute rehabilitation partner providers contributed to improved patient experience. Transitions home were supported by a 24/7 access-to-care line and a Clinical Care Coordinator to address complex patients. Key efficiency metrics included reduced acute length of stay (from 2.1 to 1.6 days for hips and 2.4 to 1.7 for knees) and increased percentage of patients discharged home (from 88% combined average in 18/19 to 95% for knees and 96% for hips in 19/20). Most significant was the reduction in inpatient rehabilitation referral, down from 15-17% in 18/19 to 1-3% in 19/20. The pathway achieved a patient reported satisfaction rate of 96% upon discharge. Onboarding of Patient Partners was critical in the evolution of our integrated pathway and continues to inform ongoing changes.


An integrated pathway for hip and knee bundle patients achieved our aim of improving patient and caregiver experience. Patient feedback was critical in identifying current gaps and opportunities for enhancing integration with technology and care navigation roles to support recovery at home.

Implications for applicability/transferability sustainability and limitations

Integrated care models have proven to be sustainable and patient-centric, ensuring strong clinical outcomes and efficiency in care delivery. In order to sustain these models, it is critical that efficiencies are re-invested to support recovery at home through care navigation role and technology.

How to Cite: Alvares M, Mian-Valiante S, Groe S, Veillette C. Learnings from the field – An Integrated model of care for Hip and Knee Bundle Patients at UHN. International Journal of Integrated Care. 2022;22(S2):8. DOI:
Published on 16 May 2022.


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