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Canadian Hospital Integrated Care 2026 — Coordination, Primary Care & Transition Guide
Complete guide to Canadian hospital integrated care — primary care reform, care coordination, transition between hospital and community, shared care plans, Infoway interoperability, and integrated care software.
~5M Canadians lack a family doctor. Infoway supports interoperability for integrated care. Good transitions reduce readmissions. This guide covers Canadian integrated care.
Integrated Care Models
| Model | Description | Key Components |
|---|---|---|
| Hospital-to-home | Support transition from hospital to home | Discharge summary, follow-up, community support |
| Hospital-to-LTC | Support transition to long-term care | Clinical handover, medication, care plan |
| Shared care | Shared care between GP and specialist | Shared care plan, shared records |
| Coordinated care | Care coordinator for complex patients | Care coordinator, multi-disciplinary team |
| Primary care network | Network of GPs and allied health | Team-based primary care |
| Health link | Care coordination for complex patients (Ontario) | Care coordinator, 24/7 access |
Care Transition Checklist
- Discharge summary: Complete and send discharge summary to GP within 48 hours
- Medication reconciliation: Reconcile discharge medications with pre-admission
- Follow-up appointment: Arrange follow-up appointment before discharge
- GP notification: Notify GP of discharge and follow-up needs
- Community support: Arrange community support (home care, allied health)
- Patient education: Educate patient and family about post-discharge care
- Discharge medications: Provide discharge medications and prescription
- Post-discharge follow-up: Phone follow-up within 48 hours
Frequently Asked Questions
- How is Canadian primary care organised?
- Canadian primary care is predominantly fee-for-service GP-based. Models: 1) Solo/group GP practice (traditional), 2. Family Health Teams (Ontario — multi-disciplinary), 3. Primary Care Networks (Alberta), 4. Community Health Centres, 5. Nurse practitioner-led clinics. ~5M Canadians lack a family doctor. Primary care reform is a priority — team-based care, virtual care, and improved access.
- What is care transition in Canadian healthcare?
- Canadian care transition is the movement of patients between care settings: 1) Hospital to home, 2. Hospital to LTC, 3. Hospital to community care, 4. Primary care to hospital, 5. ED to community. Good transitions require: discharge summary, medication reconciliation, follow-up appointment, GP notification, community support, patient education. Poor transitions cause readmissions.
- How does Infoway support interoperability for integrated care?
- Canada Health Infoway supports interoperability through: 1) Provincial EHRs (ClinicalConnect, Netcare, etc.), 2. PrescribeIT (e-prescribing), 3. Healthcare identifiers, 4. FHIR-based APIs, 5. SNOMED CT (clinical terminology), 6. National interoperability standards, 7. Secure messaging. These enable data sharing between providers for integrated care.