Transforming Healthcare: Calgary Foothills' Journey Towards Patient-Centric Integrated Community Care

Integrated care thrives when built around the patient, not on them navigating the system. This principle guided Calgary Foothills Primary Care Network's case collaborative program, initiated over five years ago. Approximately 20% of Canadians face mental health or addiction issues annually, and 57% seek initial professional help from family doctors. The intricacies of modern healthcare demand provider collaboration, but a structured framework is lacking. Feedback from patients and families illuminated challenges in navigating resources and coordinating care. In response, the case collaborative initiative emerged, uniting doctors, healthcare professionals, schools, communities, and government services. This collaborative model addresses the complex health, psychological, and social needs of patients. Co-designed by the Primary Care Network and community partners, with input from patient advisors, it aligns with best practices like patient-centered care, team-based care, population-focused care, evidence-based, and quality improvement. The successful implementation of four case collaboratives has addressed 223 cases, focusing on concerns such as a lack of family resources, coordination of care, housing, financial issues, and social isolation. Evaluation results show that 85% of providers believe the model facilitated timely connections to resources, 91% believe it enhanced patients' quality of care, and 100% felt empowered to provide care. Patients reported feeling better supported, emphasizing the collaborative team's significant impact. The strengthened relationships among providers have not only benefited directly involved patients but have created a ripple effect, enhancing overall service delivery in the community. Our presentation emphasizes integrating primary health care with patients and families as active partners. We'll outline the transition from traditional primary health practices to an integrated community care model, focusing on the co-design of the case collaborative model, key principles, challenges, learnings, and enablers supporting its success. Our goal is to contribute to a primary care collaborative that leads to better health, care, and value. Our future steps include enhancing patient engagement, transitioning to an inclusive model where families serve as primary referrers, and scaling the model provincially, nationally, and internationally.