Patient and provider experiences in an Integrated Care Pathway in Toronto, Canada: A realist evaluation

Background: The fragmented state of Canada current healthcare systems has resulted in disjointed and siloed care between acute care, and home and community care providers, affecting how patients experience care in the community. An effective solution is the refinement and implementation of existing integrated models of care to fill these gaps, place patients at the center of care decisions, and optimize patient and system outcomes.Our qualitative evaluation incorporates an interactive system within a Realist framework of an existing integrated care program (ICP) which supports patients following a hospital admission in Toronto. Our study design will uncover major factors and causal mechanisms that can be used to understand, and identify facilitators and barriers across key systems, functions, and relationships. The culmination of these findings help inform program refinement and the spread of the ICP with acute care involvement in other provinces.

Approach: Situated within a broader mixed-methods evaluation, contextual factors were identified a priori through consultation with project stakeholders and co-investigators, alongside a literature review to reflect consistency with Ontario Health Quality Standards in Care Transitions, and international quintuple aims for optimal health system performance. Program-specific information on different dimensions of care and patient-reported outcomes were obtained through interviews with a) adult patients (8 years old) who consented to be contacted via a post-discharge program survey within a 3-month period following program entry, and b) integrated care leads, and healthcare providers who referred and/or cared for at least 0 patients enrolled in the program from April 2023 onwards.Themes were identified using an iterative constant comparative process with descriptive and interpretive analysis, involving open-coding and identifying themes using NVivo 4. A lead patient partner and a public advisory committee, consisting of patient and caregiver partners, were consulted on a quarterly basis to co-design interview guides, review operational challenges and analyses, and interpret/formulate findings.

Results: 44 interviews were conducted with 6 patients, 3 integrated care leads, and 5 healthcare providers between October 2023, and April 2024. Themes will be organized into three levels: a) micro the individual perspectives of patients and healthcare providers on their interactions with the ICP (with attention to health-equity, and related consideration of intersectionality), b) information pertaining to healthcare and community organizations, and their collaboration and coordination within the ICP, and c) macro broader policies and regulations that support or hinder the ICP. Across all levels, social determinants of health will be analyzed to measure their impact on program effectiveness.

Implications: Findings from the interviews will help a) guide the refinement of the program for future scale and spread to patients with complexity, frailty, or multimorbidity and b) the development and delivery of interviews for this population, patient caregivers, and primary care providers in subsequent project years to examine whether program maturity impacted patient reported outcomes. Additionally, the findings will be triangulated with the quantitative results to inform ICP development nationally.At the international level, relevant learnings include: a) actively engaging and co-designing integrated care program modifications with patients and caregivers ensures that they remain central to health interventions b) realist frameworks are particularly beneficial for learning health systems, as they uncover key contextual factors impacting the implementation and sustainability of ICPs to enable rapid program improvement and c) the identification of program facilitators and barriers at micro, meso, and macro-levels are essential for the scale and spread of programs involving acute care across different regions, and adapting them to diverse healthcare contexts.