Integrated care improves quality of life, patient satisfaction, and health outcomes while reducing service duplication and enhancing system efficiency. Integrating home care, primary health care, and community services is essential for delivering high-quality care—especially for individuals with complex chronic conditions, such as seniors with frailty—by ensuring better coordination, timely support, and a more seamless experience across the care continuum.
The 2022 Commonwealth Fund Survey shows only 54% of Canadian physicians frequently coordinate with home care, compared to higher rates in Germany (84%) and the UK (65%). To address this integration gap, the CHCA is advancing a person-centred framework, decision-support tool, and leading practices to facilitate integrated home care, primary care, and community services.
A behaviour change approach to integrated home care, primary health care and community services
A comprehensive resource that positions home care, primary health care and community services as essential components of integrated care. Grounded in the COM-B behaviour change model—focusing on capabilities, opportunities, and motivation—the framework supports sustainable integration by addressing the human factors that drive change and enable successful adoption. Within this behaviour-based approach, the framework outlines strategies across three pillars: Shared Governance, Accountability and Partnerships, Community-Based Care, and Engaged and Empowered People. Download the Framework
Distinguishing between coordinated and integrated care, emphasizing team-based care that includes health and social services.
Creating a shared vision among patients, communities, and providers to promote collaboration, trust, and mutual accountability.
Supporting individuals and families in managing care and confidently navigating complex health systems actively.
Ensuring culturally safe, personalized services that respect individual preferences and improve overall care experiences.
Investment in secure, efficient communication and information systems accessible across care settings and service providers.
Only 19%
of primary health care staff in Canada frequently make home visits compared to 84% in the United Kingdom.
The 2015 Commonwealth Fund International Survey
54% of Canadians
believe encouraging health professionals to work in teams with other types of health care providers will improve access to care.
Health Care in Canada Survey 2018
1 in 12
hospital patients had their stay extended because home and community-care services or supports were not ready on discharge.
CIHI, Home Care Indicators
29%
of primary care practices routinely communicate with a case manager or home care provider about a patient’s needs when a patient is receiving home care services.
The 2015 Commonwealth Fund International Survey
To gain a better understanding of the policy and program direction that jurisdictions are taking across Canada to facilitate integrated care between home care and primary health care, the Canadian Home Care Association (CHCA) hosted a series of discussion panels during our 2018 Home Care Summits in Prince Edward Island and British Columbia. All panel presentations were live-streamed with video content available on-demand. This paper summarizes the key discussions from each panel presentation. Download the report
These practical tools support the development of policies and services for integrated home and community-based care. The Policy Lens supports policy and system planning and the Services Lens targets operational and frontline considerations. Download the tools
A synthesis of the current body of research on the integration of health systems in the context of home care including key elements of integration and models of integrated care involving home care and various parts of the health system including: primary health care, acute care, chronic care, palliative care and pediatrics. Download the report
This framework describes the key strategies, actions and questions for each of the six Harmonized Home Care Principles that should be addressed in the development of principle-based home care standards. Download the report