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Challenge

Every Canadian province is struggling to reduce health expenditures without jeopardizing access and quality of care. Canada’s aging populations with its increasing status of chronic conditions and comorbidities is challenging our healthcare systems in every province. Our hospitals were primarily designed to serve those with acute medical concerns.

Health spending in Canada is expected to reach a new level in 2021, at more than $308 billion, or $8,019 per Canadian1. This health expenditure will represent 12.7% of Canada’s gross domestic product (GDP).

16.8%2 of the Canadian population suffers from chronic diseases. We have observed that this small percentage of the population use the larger bulk of the healthcare resources.

Integrated care systems are targeted toward this most expensive segment of the population. The goal is to break down barriers to information sharing and leverage technology to direct data to the right people coordinating the care of patients. This will allow the data to inform the care and permit patients to engage using technology to get involved in their care.

Our care is fragmented, inefficient, expensive and unable to satisfy the the growing needs to our population.

1 https://www.cihi.ca/en/national-health-expenditure-trends
2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910465

Solution

Integrated care is a shift to quality-based outcomes business model where we focus on proactive management of health in a cross-continuum system of care that is rewarded for quality, safety and efficiency of care provided to the population. 

The first step towards initiating integrated care is to identify the cohorts of patients that you want to target, identify any gaps in care and proactively address these gaps by coordinating across care venues, staff and support system. This should be done continuously over time and between visits. The care must be tailored to patients needs with the goal of avoiding emergency department visit. All of this can only be achieved if patients are proactively managed, allowing organizations to set matrix and measure performance to better outcomes. 

Partnering with Cerner will:

  • Provide a full and coordinated continuum of care for a defined population within a defined region

  • Offer patients 24/7 access to coordination of care and system navigation services and work to ensure patients experience seamless transitions throughout their care journey

  • Improve performance against a range of outcomes linked to the IHI Quadruple Aim: better patient and population health outcomes, better patient, family and caregiver experience, better provider experience and better value

  • Be measured and reported against a standardized performance framework aligned to the IHI Quadruple Aim

  • Operate with a single, clear accountability framework

  • Support any current or future integrated funding models 

  • Allow you to reinvest into frontline care


Take a digital
-first approach, in alignment with provincial digital health policies and standards, including the provision of digital choices for patients to access care and health information and the use of digital tools to communicate and share information among providers.

The benefit of an integrated care system is bringing together all levels of care primary, secondary, tertiary, rehabilitative and long-term. They all connect with any acute care system (the solution is vendor agnostic). Wherever that patient ends up in their journey, that information will be at the fingertips of any healthcare worker interacting with that patient.

Offering the opportunity for efficient care transitions and self-management education resulting in shorter hospital stays, better coordinated care, and systemic savings.

Transformation from ‘system to person and person to system’

Benefits to healthcare delivery

Digitally enabling benefits of integrated, person-centered care range from operational benefits working to achieve economies of scale and clinical benefits that enable standards of care across all venues of care, to the structural benefits of using population health analytics to match supply and demand, and transformational benefits like addressing social determinants of health through population health, using data science to reduce health inequalities, proactively identifying cohorts of diabetics, and much more.

Finally, the integrated care system should eliminate redundancies and duplication in the care process, hence improving efficiency and effectiveness of the services provided to the patient.

Benefits to patient

Patients will benefit from getting care in venues that are in close proximity to their homes, allowing easier transitions from one stage of care to the other. Therefore, the patient is now able to better navigate the health system, resulting in a better patient experience and outcomes since they are directly involved in their care process.

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Learn how partnering with Cerner to form an integrated care system will improve care across the continuum.
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