ICP for Patients With Complex Care Needs in Ontario and Alberta, Canada

The Integrated Care Pathway (ICP) model can reduce hospital readmissions and emergency department (ED) visits while improving continuity of care. This model was first developed at the University Health Network in Toronto, Ontario, and has been adapted for patients at high risk of readmission and with medical/social vulnerability admitted to general medical units in the hospitals in Calgary, Alberta. The study will evaluate the ongoing adaption and implementation of the ICP model in Calgary. ICP patients will receive the following tenets of care: 1. Continuity of care - After determining the patient's inventory of needs, study participants will then be assigned to an ICP team member who will follow them throughout their hospitalization to support their discharge planning and to advocate for their needs in hospital. 2. Intensive Case Management - The ICL will liaise with hospital, primary care and community partners to develop a tailored complex care plan to support the patient's transition home. This will be documented in the hospital's electronic medical record (EMR) and incorporated into the discharge summary at the time of hospital discharge. 3. Post-discharge support * 24 hour access to phone support within the first 2 weeks of discharge from hospital, leveraging the ICP, community stakeholders and Healthlink from Alberta Health Services. * Long-term support and follow-up in the community up to 90 days with goal of implementing and adapting the complex care plan to help patients access services and manage their chronic health conditions. The main study objectives are: 1. To adapt and implement the ICP in Calgary's 4 hospitals over a 3 year period. 2. To evaluate the implementation of the ICP in Calgary leveraging the Quintuple Aim Framework. Methods: Patients enrolled in ICP will be compared with comparator patients in control sites to evaluate the model's effectiveness. Since the ICP is new to Calgary, the research team will be evaluating how well