Integrated Care Pathways for chronic diSease
ANHP OHT partners are working together to develop Integrated Care Pathways to help manage chronic diseases in the community, starting with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF).
Integrated Care Pathways start before people enter a hospital and continue throughout their care journey.
Current Challenges
- Primary care providers have limited time to spend with each person, and chronic diseases require more time to appropriately manage.
- Barriers such as transportation and access to resources exist for patients. Resources like smoking cessation, virtual care monitoring, vaccination and pulmonary rehabilitation can help people to manage their conditions and avoid hospital visits.
- Without access to preventative care, chronic diseases worsen. People who are admitted to a hospital for COPD and CHF are more likely to be readmitted.
What WE are working towards
- Increasing access to key resources for those living with chronic disease before they become severely ill.
- Ensure people living with COPD and CHF receive the full inventory of care as outlined by the Health Quality Ontario (HQO) quality standards.
integrated care pathways projects
Integrated Care Pathway for COPD
Wound Care ICP
Integrated Care Pathway for Heart Failure
