Integrated care & transitions

Although integrated care can lead to better outcomes and greater efficiencies, there has been little widespread success with integration. The healthcare system’s rules, regulations and norms can inhibit communication, collaboration, and effective delivery of person and family centred care by interdisciplinary teams.

Many of the existing “integrated” models of care focus on defining rigid scopes of practice. The tough question to be answered is how the work of a variety of healthcare providers in the same or different settings can overlap and be complementary to provide continuity of care and reciprocal benefits, with each provider working to optimal scope of practice.

Rather than providers and settings fitting together tightly and rigidly like pieces of a jigsaw puzzle – where, for example, the hospital discharge process is modelled to fit tightly with a home care intake process – how can we ensure that there is more fluidity between providers’ roles and between settings to reflect the journeys of clients and their families?

Our current work
We are identifying which healthcare workers are best positioned to meet specific needs and by providing tools to enable communication and collaboration among team members. Our research in a variety of settings with different groups of providers will lead to the development of an evidence-based Model of Integrated Care and Transitions that can be applied to the care that is provided in and across a variety of settings. This model will help us to:
  • Identify overlapping and exclusive elements of the scopes of practice of different groups of healthcare providers 
  • Develop specifications and standards for interdisciplinary communication, collaboration and care provision 
  • Develop education modules and curricula about integrated care and transitions for different provider groups

Some project overviews

Criteria to evaluate tools for communicating safety concerns in home care transitions
This project will develop a set of criteria and a framework to evaluate tools and resources used by healthcare providers to communicate patient safety risks and issues during patient transitions.
More information
  • Project summary -- available here.
Estim Collaboration Project
This project aims to find an effective way to implement e-stimulation therapy for pressure injuries by health care providers across hospital, rehabilitation and home settings.
More information
  • Project bulletin (March 2017) -- available here.
  • Project newsletter (February 2017) -- available here.
Let’s get real about person-centred geriatric home care
High quality geriatric home care relies on collaborative, team-based delivery from multiple different providers to meet the complex needs of older adults.
More information
  • Project summary -- available here.
Integrated stroke care in home care
This is a plan to modify a therapy‐based best‐practice stroke program to one that brings all providers – including rehabilitation professionals, rehabilitation assistants, nurses and personal support workers – together to provide person-centred integrated care to people in their homes.
More information
  • Project summary -- available here.
  • Report -- available here.
  • Report appendices -- available here.
Dialogue and Storywork in support of First Nations, Inuit, and Métis cancer patients throughout oncology and primary care transition experiences
This project aimed to improve patient transition experiences, increase the availability of resources for patients and care providers, and enhance primary and oncology care provider knowledge about the care needs of First Nations, Inuit, and Métis cancer patients, their families, and communities.
More information
  • Project summary -- available here.
  • Transition Support Resources -- available here.
The potential for Personal Support Workers to bring stroke best practices to stroke survivors and their family caregivers in their homes: An exploratory study
This project was conducted to investigate the potential of Personal Support Workers to be more active supporters of stroke survivors and their family caregivers.
More information
  • Project summary -- available here.
Using an integrated care approach in the community to transition from tube to oral feeding
Tube feeding is essential for some clients, but being able to eat by mouth is preferred by many clients. Transitioning from tube feeding to eating by mouth is possible in some cases. The approaches of speech language pathologists (SLPs) and registered dietitians (RDs) working together are not well documented, and little is known about how traditional approaches to transitioning from tube feeding vary from approaches involving neuro-muscular electrical stimulation. This project involves two teams of SLPs and RDs developing consensus on each of the two approaches.
  • Project summary -- available here.
Understanding geriatric care assessment practices in home care: the Geriatric Care Assessment Practices (G-CAP) Survey
What do nurses, occupational therapists and physiotherapists in home care use to assess the needs of geriatric clients? Most use their clinical skills and not standardized assessment tools.
More information
  • Project summary -- available here.
Comprehensive Service Level Audit of Stroke Care
across the Continuum in Central LHIN
In 2013, the Saint Elizabeth Research Centre was commissioned to complete a service-level audit of stroke care across the continuum from prevention to post-acute stages. This report incorporates best-practice stroke flow from the Ontario Stroke Network’s 2012 report, The Impact of Moving to Stroke Rehabilitation Best Practices in Ontario.
More information
  • Report -- available here.
The role of Personal Support Workers in best-practice stroke care
Through research looking at the potential role of Personal Support Workers in providing best-practice stroke care, we developed the OCAR framework (Observe, Coach, Assist, Report) as a tool for bringing together the efforts of all members of a team so that the care they provide can be complementary and integrated.
More information
  • Project report – Giosa J, Holyoke P, Bender D, Tudge S, Gifford W: Observe, Coach, Assist, and Report: an emerging framework for integrating unregulated healthcare providers into interdisciplinary healthcare teams. Journal of Research in Interprofessional Practice and Education 2015(5.2), 
Recent highlights
Giosa J, Holyoke P, Bender D, Tudge S, Gifford W. Observe Coach, Assist, and Report: An Emerging Framework for Integrating Unregulated Healthcare Providers into Interdisciplinary Healthcare teams. Journal of Research in Interprofessional Practice and Practice. 2015 October 2015;5(2), , 

Giosa J, Stolee P, Dupuis S, Mock. SE., Santi S. An Examination of Family Caregiver Experiences during Care Transitions of Older Adults. Canadian Journal on Aging. 2014;33(02):137-53. Abstract available here.

Toscan JM, B; Santi, SM; Stolee, P. "Just another fish in the Pond": The transitional care experience of a hip fracture patient. International Journal of Integrated Care. 2013;13(26).

Toscan J. Mobilizing support in home and community care with Tyze Personal Networks. Rehab and Community Care Medicine. 2013;Spring (2013):32-3. Available here on p.32. 
Holyoke P. Integrating Nursing and Personal Support into the WWCCAC's Stroke Care Pathway. Oral presentation at the OACCAC Conference on Achieving Excellence Together; Toronto, ON; June 5-7, 2016. 
Lala D, Houghton P, Kras-Dupuis A, Holyoke P, Wolfe D. Exploring Key Processes in Implementation Planning: Electrical Stimulation Therapy to Improve Pressure Ulcer Healing in Community Dwelling Persons with Spinal Cord Injury. Poster Presentation at the McGill University’s 1st National Knowledge Translation Conference in Rehabilitation; Montreal, QC; May 4-5, 2016.
Bender D. Developmental Service Workers: New members on the team. Canadian Nurse. 2013;June 2013.

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