INTEGRATED HOME, PRIMARY CARE
AND COMMUNITY SERVICES

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. This approach ensures 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.

Enhanced Framework for Integrated People-Centred Care

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

Key Messages from the People-Centred Care Framework

From Coordination to Integration

Distinguishing between coordinated and integrated care, emphasizing team-based care that includes health and social services.

Vision-Driven Partnerships

Creating a shared vision among patients, communities, and providers to promote collaboration, trust, and mutual accountability.

Empowerment through Health Literacy and Self-Advocacy

Supporting individuals and families in managing care and confidently navigating complex health systems actively.

Integrated Workforce Planning

Facilitating task sharing and equitable provider distribution to build capacity and strengthen system sustainability.

Patient-Centred Outcomes  

Ensuring culturally safe, personalized services that respect individual preferences and improve overall care experiences.

Interoperable Digital Infrastructure

Investment in secure, efficient communication and information systems accessible across care settings and service providers.

TOOLS AND RESOURCES

Integrated Home Care And Primary Health Care: A Pan-Canadian Perspective

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

Home Care Lens Tool

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

Health Systems Integration: Synthesis Report

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

Partnership In Practice: National Home Care and Primary Health Care Partnership

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

This post is also available in: French

Established in 1990, the Canadian Home Care Association (CHCA) is a national non-profit membership association dedicated to advancing excellence in home and community care.

National Office: 905-567-7373     |    General Inquiries: chca@cdnhomecare.ca

2000 Argentia Road, Plaza 3, Suite 302. Mississauga, Ontario, L5N 1W1

ALL OF THIS IS HIDDEN

This post is also available in: French