As a concept, healthcare integration is very popular but it’s the
implementation process where many organizations struggle. The Fraser
Health Authority is redesigning its Home Health services and with help
from the Divisions of Family Practice, they are improving access to
community health services for patients.
practitioners (GPs) were disconnected from Home Health case managers
who coordinate care for people with complex care needs requiring ongoing
support to live at home independently. Prior to 2010, when it came to
the home care of elderly or disabled people, both groups were feeling
out of the loop with each other when it came to the care of their
- Case managers were responsible for patients within a
geographic area, but often weren’t in communication with the GP on the
health status or care plan for the patient, which led to gaps in the
care of the patient.
- Because of the disconnect between GPs
and case managers, patients receiving long-term home health services
weren’t receiving coordinated care. As a result, the patients ended up
visiting hospitals more frequently or being placed in residential
facilities, leaving a system that was inefficient, fragmented and
- The Fraser Health
Authority (FHA) recognized the disconnect and began collaborating with
the Ministry of Health and the Divisions of Family Practice to create an
initiative that integrates the work of the health authority and the
GPs. As a result, the Home Health case manager-GP partnership
initiative was created.
- Case managers are now assigned to a
specific physician’s practice and communicate with GPs on patients they
share. This allows them to better support the patient or their
caregiver in addressing their care needs and improves their ability to
coordinate services for their patients.
- GP’s with clients on
the Home Health long-term program now have one person to call when they
need to discuss the status of their Home Health patient. Case managers
and GPs are “in the know” about what the other is doing and how their
care is complementary.
- Baseline patient surveys were helpful in
demonstrating the effectiveness of this initiative. The patient survey
conducted in Chilliwack reported a dramatic decrease of overnight
hospital stays over a twelve month period.
- The patient now has more comprehensive care.
example of integration and collaboration has been successfully
implemented in Chilliwack, White Rock/South Surrey, and Abbotsford. It
is in the process of being implemented in Maple Ridge and Mission.
Through collaboration with all Divisions of Family Practice in the FHA
area, the Home Health initiative will be implemented in every community
of Fraser Health within the next two years.
Grace Park, the Medical Director of the Home Health program and also a
board member for the White Rock/South Surrey Division of Family
Practice, along with Director Irene Sheppard, attribute the program’s
success to partner collaboration and integration of resources.
- There was recognition from all partners involved that a care gap existed in the way home healthcare was being provided.
strong input from GPs and case managers was essential to improve all
aspects of patient care but also to gather feedback on how everyone
wanted to work together.
- All partners were engaged in the development and implementation of the program.
- Everyone had the same common goal and worked as a team, instead of separate entities.
Home Health initiative is a great example of the Triple Aim initiative,
which is to improve the health of the population, enhance the
experience of care for patients, families and provider and reduce or
control care costs. Download the Health Integration case study.