Integrated care means your hospital, family doctor, home care nurses, specialists and community services work as one coordinated team around you. They plan your care together, instead of each one handling a separate piece and leaving you to connect them. In Canada this is no longer just a policy idea. Ontario now has 58 Ontario Health Teams covering the whole province, Quebec runs regional networks that bring hospitals and social services under one authority, and in 2021 Canada published the world’s first co-designed national standard for integrated, people-centred care.
What Integrated Care Means and How It Works
A definition used in Canadian research describes integrated care as managing and delivering health services so that people receive a continuum of preventive and curative services, based on their needs over time and across all levels of the health system. The World Health Organization definition, which appears in Canadian policy documents, goes further. It includes services outside health care, such as social services, housing and education, because these shape health too.
The purpose of an integrated system of care is to overcome fragmentation. In practice, that usually comes down to three things:
- One team: hospitals, doctors and home and community care providers work together, wherever they deliver care.
- One record and one plan: in Ontario Health Teams, providers share one patient record and one care plan.
- One point of contact: a care coordinator (also called a patient navigator or case manager) books appointments, manages transitions and makes sure referrals and test results end up where they need to be.
Here is an example of integrated health care in action. Your father is discharged from hospital after a fall. Without coordination, you call the home care office, fax discharge notes to his family doctor and chase a physiotherapy referral yourself. With integrated care, the care coordinator arranges home care, makes sure the family doctor receives the discharge notes, schedules follow-up visits and connects him to community resources. You no longer carry it alone.
Why Fragmented Care Is Canada’s Core Problem
Canada has a universal, tax-funded system. Provinces and territories deliver health care and regulate providers. The federal government sets national standards through the Canada Health Act and provides funding. Many services are publicly paid but privately delivered, and each province decides which services count as “medically necessary” and are insured.
The result is a system split into silos. Hospitals, specialists, prescription drugs, primary care and home and community care are each paid from a separate funding envelope, with no shared financial incentives. Health policy experts link Canada’s repeated poor showings in OECD comparisons to provinces’ failure to change these siloed delivery models. Data is another hurdle: many jurisdictions and authorities have their own data needs and processes, so sharing information smoothly is difficult.
The risk of fragmented care is high for people living with several chronic conditions. When no one coordinates, setting treatment priorities across different providers becomes a real challenge.
Who Is on the Care Team and What Services It Offers
Research on integrated care teams lists a wide range of care providers: primary care physicians, acute care hospitals, home care, community support services, mental health and addictions services, rehabilitation, palliative care, emergency services, and laboratory and diagnostic services.
Home and community care, the part families most often deal with, can include:
- Nursing, family medicine and social work
- Personal care (bathing, feeding, dressing) and homemaking
- Physiotherapy, occupational therapy and speech therapy
- Dietitian and psychologist services
- Respite services and caregiver supports
- Friendly visitor programs, meal delivery and day programs for people with dementia
Ontario Health atHome care coordinators are regulated health professionals with backgrounds in nursing, social work, occupational therapy, physiotherapy or speech therapy. They meet patients in hospitals, doctors’ offices, schools and at home.
The Four Levels of Integrated Care
Researchers Fulop and colleagues (2005) described four levels at which care can be joined up:
| Level | What is joined | What you might notice as a patient |
|---|---|---|
| Organizational | Organizations are linked or governed together | Hospital, primary care and social services under one regional authority, as in Quebec |
| Functional | Support functions such as records, planning and finance | One shared patient record across providers |
| Service | Different services are delivered as one package | Home care arranged at discharge |
| Clinical | Professionals coordinate care for the individual patient | One care plan your doctor, nurse and therapist all follow |
An international Delphi study (Zonneveld et al., 2020) added a values layer at four levels: personal (“trustful”), professional (“collaborative”), management (“efficient”) and system (“comprehensive”). Canada’s CAN/HSO 76000:2021 standard sets out 66 detailed, action-oriented criteria for policymakers and health system partners.
How Integrated Care Looks Across the Provinces
Because provinces and territories run their own systems, integrated care looks different depending on where you live:
| Province or program | Approach |
|---|---|
| Ontario | Started with 24 Ontario Health Teams and now has 58 covering the entire province. Twelve OHTs were chosen to speed up home care delivery as part of the move to Ontario Health atHome. |
| Quebec | Regional networks (CISSS and CIUSSS) integrate hospitals, primary care and social services under one authority, alongside interprofessional primary care teams. |
| British Columbia | Interprofessional primary health care teams, with policy built on patient-centred care and team structures. |
| Alberta | Announced in 2023 that its centralized integrated system would be split into three organizations for acute care, primary care and continuing care, reversing earlier centralization. |
| Nova Scotia | Launched a virtual care policy in 2020, particularly for rural patients without easy access to specialists. |
| First Nations and Inuit | The federal government invested $185 million over five years, starting in 2017/2018, in the First Nations and Inuit Home and Community Care program, with $69.1 million per year ongoing. |
BC, Alberta, Ontario and Quebec all use interprofessional primary health care teams. Five components drive integration in these teams: patient-centred care, team structures, information systems, financial management and performance measurement.
How Integrated Care Improves Patient Outcomes
The evidence is encouraging, though it has limits:
- Satisfaction and access: A systematic review of 167 studies (Baxter et al., 2018) found increased patient satisfaction, better perceived quality of care and improved access to services.
- Hospital use: A review of 26 studies (Liljas et al., 2019) found integrated care tends to lower hospital admission rates and has some positive effect on length of stay.
- Readmissions: One study of integrated programs for people with chronic conditions found a 40% drop in readmissions for acute flare-ups and a 57% drop in all-cause readmissions.
- Multiple chronic conditions: Integrated interventions have been shown to strengthen primary care functions and reduce gaps in care.
Cost savings are less clear. The same 167-study review rated the evidence for lower health care costs as limited. Bundled payment models, where one funding envelope is shared across several providers, have reduced costs while keeping or improving quality in the US, the Netherlands, England and Germany. Canadian examples are still rare.
Common Myths About Integrated Care
- “It’s the same as integrative care.” Integrated care is about how services are organized and coordinated. “Integrative care” sounds similar but is a different term. If a clinic uses either term, ask what it means there.
- “Integrated means everything is free.” Coordination doesn’t change what’s insured. People without extra government benefits pay for home care, prescription drugs, dental care, vision care and ambulance services themselves or through private insurance. Coverage varies by province.
- “Every care coordinator has the same training.” The role isn’t standardized or regulated across Canada, and qualifications vary widely. Ontario Health atHome is an exception: its coordinators are regulated professionals.
- “It’s proven to save money.” Benefits for satisfaction and hospital use are better supported than cost savings.
- “A coordinator replaces the doctor.” Coordinators organize care; they don’t replace your doctor. If symptoms are new, getting worse or worrying, including mental health concerns, see your doctor promptly. In an emergency, call 911.
How to Ask for Coordinated Care: A Family Checklist
- Ask your primary care provider: “Is there a care coordinator or patient navigator in this clinic, or through our local Ontario Health Team?” (Outside Ontario, ask about your provincial equivalent.)
- Before a hospital discharge: Request a discharge planning meeting. Ask whether a referral to Ontario Health atHome or the provincial home care program has been made, and who the assigned care coordinator will be.
- Request a needs assessment: Call your provincial home and community care intake line, or in Ontario, use the Ontario Health Team online directory.
- Review the care plan: After the assessment, the coordinator writes an individual care plan, works with the primary care provider to track progress and updates the plan as needs change. Ask for a copy.
- Ask about culturally specific navigation: For example, Niagara Health’s Aboriginal Patient Navigator Program offers navigation designed for Indigenous patients and families.
- Ask about new programs: The federal Shared Health Priorities agreement provides $6 billion over 10 years to expand home and community care. Ask whether new services funded through it are available in your region.
- Check costs early: Find out which services are publicly covered in your province and which you would pay for yourself.
Frequently Asked Questions
What is the three-month rule in mental health?
In Canadian health coverage, the three-month rule refers to the waiting period for provincial health insurance after moving to a new province. It is not a mental health rule specifically, but it affects access to all insured care, including mental health care. British Columbia applies a three-month wait, while Alberta has none. If you’re moving, check your new province’s rules before you go.
Who owns integrated home care services?
No single owner runs them. Provinces and territories are responsible for delivering health care and regulating providers, and many services are publicly paid but delivered by private providers. In Ontario, home care is organized through Ontario Health atHome and Ontario Health Teams.
What services are offered at an integrated care centre?
Services vary by location. Typical options include family medicine, nursing, social work, rehabilitation therapies, dietitian and psychologist services, mental health and addictions support, personal care, respite and caregiver supports.
How is integrated care different from integrative care?
Integrated care describes how providers coordinate around you: shared records, one plan and one point of contact. Integrative care is a separate term; if a provider uses it, ask what it means there.
What are the benefits of integrated care?
Reviews link it to higher patient satisfaction, better perceived quality, improved access, fewer hospital admissions and, in one chronic disease study, 57% fewer all-cause readmissions. Evidence on cost savings remains limited.