Bringing the best of health and care together.

UHN's Integrated Care Program is changing the way care is delivered and experienced in Ontario and beyond.

This program supports a number of models that wrap care around our patients and makes it easier to communicate and coordinate care plans. Through this program, patients have:

  • One point of contact
  • One record for the care team to collaborate
  • One support line available 24/7

Critical to the patient experience is the connection with an Integrated Care (IC) Lead whose role is to bring all care providers (e.g., hospital, homecare, primary care, etc.) together and ensure continuity of care, including helping patients get home as soon as possible and stay there.

In other words, IC removes the barriers and burdens associated with navigating and coordinating care for patients, and creates much-needed capacity via:

  • Patient education and self-management
  • Delivering more advanced care at home
  • Decreasing length of stay
  • Avoid unnecessary readmission and visits to hospitals

This in turn addresses the surgical and clinical care backlog, reduces hallway health care, and provides opportunities to modernize home and community care in a scalable and sustainable way.

To put it simply, the Integrated Care model frees up beds, clinician time, and keeps patients, as much as possible, at home and in their communities.

Our approach is led by patients and what they want, follows international integrated care best practices, and will continue to be designed by patients to support the following:

One team

three clinicians looking at a chart

One consistent care team with a primary point of contact

One Digital Record

woman looking at smartphone
Communication &
Continuity of Care

One story to tell, enabled by a shared digital record

One Number to Call

woman with smartphone to her ear
Easy &
Timely Access

One 24/7 phone line available to patients and caregivers

One Integrated Fund

two open laptops and papers on a table

One integrated fund to allow for flexibility for patients when and where needed


Focus on patient & caregiver needs.


Support care provider satisfaction & quality of work life.


Care model as driver of the integrated funding model.


Co-design and commitment to meet key metrics.

Integrated Care
Guiding Principles


Digitally enabling connected care.


Ensure sustainability and scalability.


Provide equitable care.


Shared accountability & transparency.

Creating a New Standard of Care

The success of the IC Program stems from UHN's investment in people and systems. We want an integrated care experience to be the standard of care for all individuals. Through partnerships, we bring together programs, providers and services to create new models of care. Each model of care is rooted in providing safe and high-quality care using proven protocols, while responding to the unique needs of each patient's medical and personal circumstances.

At UHN alone, we currently support thousands of patients annually with our growing list of IC pathways:

  • Surgery (Cardiovascular, Orthopedic, Thoracic, Vascular)
  • Medicine (CHF, COPD or COVID+ diagnosis)
  • Transplant (Liver)
  • Emergency Department (Respiratory Conditions, CHF and COPD)

We are expanding rapidly across UHN in FY 2023/24 and FY 2024/25 and work in partnership with Ontario Health (OH) Toronto Region, VHA Home HealthCare and partners, and other service providers and stakeholders across the GTA.

In addition to our efforts to support patients seeking care at UHN, we are also leading efforts beyond our walls to advance the ability for individuals in Ontario and beyond to benefit from an integrated care experience. Early efforts are already being leveraged across the Toronto region in leading demonstration projects for CHF and Diabetes as well as in addressing population health needs for older adults through our work with the NORC Innovation Centre. These efforts are being delivered and spread more broadly by our UHN Connected Care team.

For more information, please email

I would like to thank you for your help during this difficult time. You were both knowledgeable and helpful with your advice and guidance in helping me navigate the difficulties that I encountered during my healing.

All patients should have an integrated care experience, one that puts you and your caregivers first and includes you in the care planning so that your care is seamless and customized to your needs.

UHN is leading efforts to ensure all individuals can have an integrated care experience as a standard of care. We do this work within our hospital walls but also across the GTA, Ontario and beyond.

Specifically, if you are a UHN patient, our Integrated Care promise to you is to: keep working until we achieve the highest patient satisfaction, deliver the best health outcomes and continue to create possibilities that allow you to stay at home or in your community as much as possible.

This program will continue to grow and improve with learning and feedback. Currently, if you are enrolled in this program, you will receive proven support as early as possible including pre-surgery or first visit to one of our sites.

Critical to delivering the best care experience is to connect you with an Integrated Care Lead (IC Lead). Your IC Lead will support you and your caregivers as a primary point of contact and will help coordinate services and supports, including primary care, home and community care, in partnership with trusted care providers from the community. Home care is a large part of the care needs required by patients leaving the hospital and as such we are growing UHN@Home to build out our dedicated and specially trained team.

Being enrolled in the Integrated Care program you will benefit from having one:

  • Primary point of contact
  • Coordinated care team
  • Medical Record
  • 24/7 support: Please call 1 833 978 2024 for any questions you or your caregiver may have

Your designated care team will work with you:

  • Create a care plan that is suited to you and your unique healthcare needs
  • Work closely with all members of your care team
  • Help make your transition out of hospital as easy as possible
  • Coordinate and manage your home care and community support services
  • Communicate with your primary care provider and specialist(s) about your care
  • Identify support services you may need when leaving the hospital, such as nurses, physiotherapists, respiratory therapists, and personal support workers
  • Introduce you to community resources to help you live independently

[My IC Lead] displayed a remarkable level of empathy and understanding towards my father's needs. She took the time to listen attentively to his concerns, ensuring that he felt heard and supported throughout the entire process.

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