Co-creating the conditions to advance integrated care: Insights from UHNs five year journey in Toronto

Background: In 2024, the University Health Network, Canada’s largest research hospital celebrates five years since embarking on a journey to change the way care is experienced and delivered in Toronto, Ontario. UHN tasked its Connected care team with a mandate to address system-wide issues related to care coordination, communication, continuity of care and lack of personalized care. Leveraging data to identify opportunities, the population served by UHN lives right across Toronto and requires a focus on the unique needs of the 6.3 millions residents in one of the most multicultural centres in the world. Objective: This paper delves into the leadership insights gained by UHN Connected Care over the last five years, highlighting the collaborative efforts involving patients, care partners and healthcare providers. Taking advantage of pressing health system needs, learnings shared come from efforts to address poor patient experiences and outcomes, provider burnout and health system capacity issues.MethodsIn 209, the Connected Care team initiated an integrated care approach, implementing a collective impact strategy that brought together patients, care partners, local and regional providers and funders. The methodology was built on key pillars: Backbone support - centralized supports and dedicated tamOpportunistic interventions - work together on pressing shared concernsPartnership and accountability - leverage and recognize areas of expertise Co-create - incremental solutions developed together Recognition of all voices - provide opportunities for all leadersPatient partners led all aspects of planning, delivery and evaluation. By offering a range of opportunities requiring different levels of commitment, the team ensured there was ongoing and consistent help and support to participation and representation. For example patients could be involved in interviews to support specific care pathways, to leading the development of a minimum patient experience data set, to longer term commitments on working group and committees. Results - over the course of five years, the initiative expanded its reach from addressing issues within a surgical division to growing city wide pathways, positively impacting the lives of thousands of individuals. Outcomes include a reduction in emergency department visits, hospital stays and surgical backlogs. This not only improved patient satisfaction but also bolstered the overall capacity of the healthcare system. The collaborative efforts extended across the care continuum to encompass primary, acute and home care teams, as well as community paramedicine, pharmacy services and various social support organizations. The relationships and trust built across the city have created an integrated health and social network that continuously leads and learns together. Conclusion and Next Steps - Future efforts to scale and spread integrated care through community partnerships will continue to increasingly support population health with a more concerted effort to provide much needed integration with new partners to address social determinants of health supports. The team is also now embarking on an ambitions multi-year strategy to develop an integrated care digital platform. One crtical area of growth has been initiated to explore the potential of aging in place program with a focus on community-led interventions that will support hyper-local needs and expand service provider partnerships.