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Group shot of doc, 2 nurses
More than 200 patients have enrolled in Integrated Care at UHN since it was launched in June in the Thoracic Surgery Program, where Dr. Tom Waddell (C) is the Division Head of Thoracic Surgery, and Kimberly Pavli Clark (L) and Emily Hannon are IC Leads. (Photo: UHN)

Frank Proctor felt like a whole team was looking out for him.

A few days before Frank underwent surgery at Toronto General Hospital last summer to remove two nodules on his left lung, registered nurse Emily Hannon offered her phone number – and a promise. If he needed anything, at any time, before or after his stay in the hospital or when he got back home, he should just give her a call.

Over the next month, he reached out twice. The first time, after he pushed himself too much on a walk, Emily had a homecare nurse dispatched to Frank's Stouffville farm. The second time, when he caught a virus, she contacted a nearby hospital in Newmarket for him to have X-rays, which were promptly made accessible to UHN physicians, meaning he didn't have to travel far and avoided an Emergency visit.

"I felt very comfortable knowing that if anything happened, she had my back," says Frank, 77, who continues his recovery from the surgery in late July and is back hosting a series of weekly radio shows. 

"Once I checked out of the hospital, the care didn't end there. They were continuing to monitor me."

This is Integrated Care (IC) at UHN, launched in the Thoracic Surgery Program in June and set to expand across other surgical programs and beyond, including into social medicine, where the integration will also be comprised of programming for high-needs patients.

Embodying the UHN Strategic Priority to "inspire, invent and deliver tomorrow's care," the goal of Integrated Care at UHN is a better care experience – for patients and caregivers, and healthcare providers – while being more cost effective and improving patient outcomes and population health.

"I was privileged to play a role in creating this model and observed firsthand how the care experience was improved for patients, their families and care providers at St. Joseph's Healthcare Hamilton," says Dr. Kevin Smith, UHN President & CEO. "Now, TeamUHN is partnering with the St. Joseph's Health System's Centre for Integrated Care to bring our collective expertise and experience together.

"This will further expand the model. We'll quickly see patients, families and frontline staff creating solutions together.  

"We're already seeing how focusing on the comprehensive care experience can lead to successful and sustainable care improvements to support diverse patient populations."

A lot of great work has been done across UHN on integrated care. This IC model is not only built on those successes but also looked at best practices in other jurisdictions across Canada, and internationally, to deliver UHN's integrated care promise:  one care team, one digital patient record, and one 24/7 phone line for patients and caregivers. It is enabled by one integrated fund that gives the IC team flexibility to respond quickly as patient needs change.

Frank Proctor
Frank Proctor enrolled in Integrated Care at UHN prior to lung surgery in late July and twice in the first month after he got home used the 24/7 phone line to connect with his IC Lead. (Photo: Courtesy Frank Proctor)

St. Joseph's Health System (SJHS) developed this evidenced-based model of integrated care. To date, it has served more than 20,000 patients with a 98 per cent satisfaction rating. It has helped patients go home sooner, reduced their need to go back to the Emergency Department and decreased readmissions into hospital for care.

"This is another step forward for patient care," says Dr. Carolyn Gosse, Vice President of Integrated Care at SJHS and President of St. Joseph's Home Care.  "Working with TeamUHN, VHA Home HealthCare and the TC-LHIN has been a great experience.

"Our collaboration to apply the IC model will lead to improved patient experience by placing patients at the centre; and will help our healthcare system to build capacity."

The goal is a more seamless transition for the patient from the hospital to home, a better coordination of care services, improved communications and a clearer understanding of the plan of care.

It's hoped that UHN can achieve similar results to those seen at SJHS.

In the Thoracic Surgery Program, once patients are referred by their family doctor to see a specialist at UHN and a decision is made to operate, the introduction to Integrated Care at UHN is made.

Patients and caregivers meet the clinical team, including either Emily or her fellow IC Lead, Kimberly Pavli Clark. Even before surgery, patients have access to the two longtime nurses and a 24/7 dedicated, toll-free support line staffed by them or an after-hours nursing team.

How can you get involved?

Integrated Care at UHN is about delivering tomorrow’s care experience – we need your help and innovative ideas. If you’d like more information or have an idea to share please contact Shiran Isaacksz, Sr. Director, UHN Connected Care, who is leading this critical program at shiran.isaacksz@uhn.ca

Within 24 hours after surgery, one of Emily or Kimberly meets the patient and caregiver at Toronto General to support the transition to home. Once the patient is discharged, one of the IC Leads at UHN is in contact and remains accessible through the dedicated support line.

Homecare, provided in the five Local Health Integration Networks (LHINs) around the Greater Toronto Area by VHA, which is designated by the Registered Nurses' Association of Ontario as a Best Practice Spotlight Organization, is available for up to 90 days post-discharge depending on patient needs.

And, as those needs change, so can the type of visiting VHA clinician, who have received specific training, both in-house and by UHN, on dealing with thoracic patients.

As IC Leads, Emily and Kimberly remain the primary point of contact on the patient's care team. In turn, one shared digital health record tracks all in-person homecare visits, supplies and equipment, and follow-up appointments with UHN physicians.

The pair is also in daily contact with a VHA supervisor dedicated to the IC program to review cases, discuss challenges that arise and ensure patients are getting the care appropriate for them from among the 90 clinicians, including nurses, personal support workers and a variety of allied health professionals.

"Before, there was a big disconnect between the care in the hospital and the care in the community, so it was easy for the patient to get lost in the system," says Emily, a thoracic nurse for 12 years. "Now, we're able to streamline the process for the patient and offer that direct information and links for the care team to support one another."

Kimberly, a nurse for lung transplant patients and a patient care coordinator during nearly 10 years at UHN, says bringing together all of the often disparate healthcare teams involved in the journey of a thoracic patient from the community to hospital and back again offers "a more holistic view" of care.   

"All of the feedback we're getting is that the program is alleviating the anxiety of patients and helping them navigate the system much better," she says.

3 VHA staff members
Key members of the VHA Home HealthCare team working on UHN Integrated Care include (L to R) Hemjot Mal, Courtney Bean and Christina Darlington. (Photo: UHN)

Dr. Tom Waddell, Division Head of Thoracic Surgery at UHN, says as medicine has over the years become more complicated, specialized and inward-looking, patients have found it increasingly difficult to access the care they need when they need it. As a result, their experience in the system has been frustrating.

"It's really important we help patients navigate between these big, tall silos of technical expertise," Dr. Waddell says. "A lot of it is about information flow, getting one group dealing with the patient in one area to talk with those in another area, all with an eye to improving patient outcomes and experience.

"Integrated care is a lofty ambition and challenging but we're definitely on the right trajectory of trying to do a better job of connecting the various parts of a patient's journey."

Through the end of October, more than 200 thoracic surgery patients were enrolled in Integrated Care at UHN. Though it's too early to tally savings to the system, it has resulted in decreasing time patients have to spend in the hospital and several avoided Emergency Department visits and potential readmissions.

And, as Frank Proctor will attest, it appears patients are receiving a much better managed experience.

"The whole idea of being followed through the system is marvelous," he says.

"As a patient, it feels like everybody's connected and you're the centre hub of the wheel."

Rather than reinventing the wheel, UHN is building its IC program in partnership with community partners. As a result, the delivery team for the program is broad in its makeup – both within the organization and beyond.

The UHN IC team working to deliver this program includes members from UHN's Surgical/Thoracic, Connected Care, Digital, Finance, Legal, Privacy, Security, Decision Support, Human Resources, Healthcare Human Factors and Patient Partners, in addition to St. Joseph's Home Care, VHA and support from the Toronto Central LHIN.

They all work collaboratively as one care team.

The Independence
Phyllis Berck, one of two Patient Partners on the UHN Integrated Care team, says the two of them were always seen as key participants in the meetings and encouraged to offer their unique insights as patients. (Photo: UHN)

"Knowing that through this kind of partnering between acute care and home care we were designing something that was truly better for the patient was such a win," says Courtney Bean, Director, Client Services, VHA Home HealthCare.

"From the moment the patient joins the program, they have more of a voice than they had in the past and that helps us provide even better client-centred care."

For example, if one patient tells an IC Lead she's not a morning person, then a VHA clinician will do their best to make an appointment for later in the day. Or, if another's needs to move from nursing to rehabilitation quicker than expected, the care plan can be adjusted before the next visit.

"There will always be financial realities, but the process is much more nimble and flexible around what the patient needs," Courtney says. "If things need to happen differently for that patient, they do."

A key component of the evolution of Integrated Care at UHN was the perspective provided by the two Patient Partners on the team, Phyllis Berck and Lyn Gaetz. Far beyond simply attending the regular meetings, they offered unique insights, such as the need to connect with patients early.

"When a patient comes into the hospital for surgery or other complex treatment, they're just terrified," says Phyllis, recalling her feelings three years ago when she had a mastectomy and breast reconstruction surgery. "So it's important to let them know before they come in that you're there for them.

"It's also important to help them prepare for the recovery process as early as possible.

"When you do those things, their anxiety level just drops."

To that end, the UHN program invests time upfront meeting with patients and caregivers before the surgery date to discuss what their needs will be when they go home and reassure them help with any concerns or challenges after discharge is only a phone call away.

Where relevant "pre-habilitation" – health interventions provided prior to surgery – has also been included as part of the care plan where home care support is provided to support a faster and smoother recovery after surgery.

Frank Proctor has a follow-up appointment with his surgeon later this fall. In the meantime, he's feeling good and happy to take a break from his busy life to applaud the Integrated Care experience at UHN.

"You have people extending a hand, helping you up the stairs," he says. "I was glad to take it."


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