Background
Hospitals face significant challenges during winter due to the seasonal influx of patients with illnesses such as influenza and COVID-19, a phenomenon known as the "Winter Surge." East Toronto Health Partners, in their efforts to build an integrated care system across settings, aimed to address this issue by facilitating early discharges and supporting patients' transitions from hospital to home through a collaborative initiative called the Hospital Nice Fund (HNF). The HNF program exemplifies a community-enabled partnership designed to improve population health and well-being. Its goal was to expedite discharge for clinically cleared patients facing social barriers by providing community or home care services. This project aimed to conduct an outcome evaluation using quantitative methods, with findings intended to inform future investments in collaborative care efforts.

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Approach
We evaluated healthcare utilization among HNF enrollees compared to similar patients not enrolled in the program. Using propensity scores, we matched HNF enrollees with a control group in a 1:3 ratio and employed a difference-in-differences approach with generalized estimating equations to assess the association between HNF enrollment and key outcomes: hospital length of stay (LOS), 7-day emergency department (ED) visits, and 30-day hospital readmissions. The study period spanned from December 1, 2018, to April 30, 2022.

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Results
A total of 456 control patients were matched to 152 HNF enrollees. After matching, baseline covariates between the two groups were balanced, with standardized differences below 0.10. The mean age of enrollees was 72.8 years, and 51% were male.

Preliminary results showed that, although not statistically significant, HNF participants had longer hospital stays (an average of 4.1 days) compared to non-HNF patients. Additionally, 30-day readmission rates were higher among HNF participants, with approximately three times the odds of readmission compared to non-HNF patients. Similarly, 7-day ED visits were more frequent among HNF participants, with the odds of an ED visit being about 5.5 times higher than for non-enrollees. These findings suggest that the HNF program may need adjustments to improve patient flow during the Winter Surge.

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Implications
This study is among the few that utilized advanced quantitative methods to evaluate the outcomes of integrated care, focusing on its impact rather than implementation. The findings highlight the critical role of integrated care in advancing health outcomes but also suggest that adjustments to the HNF program may be needed.

The decision to avoid strict enrollment criteria likely facilitated discharges by enrolling patients with longer LOS to free up beds. However, this may indicate that the program’s inclusion criteria or goals need refinement to better align with patient needs. Additional community or home-based support may also be necessary to prevent readmissions and ED visits. Further investigation is required to determine how the program can be optimized to enhance patient flow and outcomes.

Background
As part of our Regional Hospital System's multi-year systemic transformation aimed at accelerating continuous and coordinated integrated care across the entire Hospital System, the redesign of clinical governance was identified as key to ensuring integrated care outcomes and value; a better accountability framework for physicians was needed to drive outcomes and value improvement and foster a culture of excellence.

Approach
We developed the physician accountability framework guided by the iterative three-step process from the Health System Transformation Playbook, involving storytelling, model building, and pathfinding. We first analysed 2023 hospital data on patients' care trajectories, healthcare costs, and lengths of stay to identify patterns and areas where physician accountability could be clearly defined.

Building on these insights, we collaborated with departmental leaders, senior physicians, and subspecialists to conduct iterative storytelling sessions, where physicians shared their experiences on care coordination and patient outcomes. Through these discussions, we identified key inflection points where physicians' decisions directly influenced patient outcomes. This enabled us to design the accountability framework for "episodic care", where accountability is assigned based on care initiation, transitions between subspecialties, and discharge management.

Results
The accountability framework provides clear rules to define each physician's scope of accountability and contributing responsibility in patient outcomes. Key principles include:
•The period of accountability for “episodic care” begins with an inpatient admission and concludes 90 days after discharge or on the day before a readmission.
•The consultant in-charge of the patient’s care at the point of discharge is held accountable for outcomes of the entire “episodic care” period.
•Specialists, from other departments, who contributed to patient’s care share responsibility based on their seniority.

This framework is incorporated into our Systemic Integrated Care Dashboard that provides actionable insights on patient outcomes, including clinical outcomes, patient experiences, and healthcare costs. These insights enable physicians to track the impact of their care decisions, while departmental leaders monitor performance and guide improvements. By structuring accountability across the care process, we have introduced transparency and fostered a shared responsibility model, enhancing care coordination and patient outcomes.

Implications
Understanding the mapping of systemic performance measures to different physicians involved in the interdisciplinary delivery of integrated care throughout a patient’s journey will delineate accountability more coherently. This governance transformation signals a shift in how responsibility for patient integrated care outcomes is structured, focusing initially on physicians, but with future plans towards a broader inclusion of the range of healthcare providers potentially involved in integrated care into the accountability framework. In the long term, this framework aims to foster a mental model of shared accountability, ensuring a holistic and collaborative approach to continuous and coordinated patient care, where all members of the healthcare team are aligned in delivering high-quality outcomes.

Additionally, the framework highlights the importance of mentorship within subspecialty departments to ensure junior physicians are consistently supported in delivering high standards of care. This emphasis on mentorship not only improves clinical outcomes but also foster a culture of continuous learning and professional development within a Regional Hospital System delivering integrated care.

Background
Most intermediate care is provided at home, but some people receive ‘step up’ or ‘step down’ intermediate care in dedicated beds in community hospitals or care homes. Rehabilitation is a core function of the contemporary community hospital which offers a slower-paced and more homely setting than acute hospitals and an environment that is conducive to recovery and reconnecting with family. This workshop, a collaboration between the UK Community Hospitals Association and IFICs Intermediate Care SIG, introduces a new international network on community hospitals (CH), building on a ‘soft launch’ international webinar in November 2024.

Audience
The interactive workshop will be of interest to policy makers, researchers, advocates, patients, carers and professionals who plan, commission, fund, provide or regulate care and support services for older people or adults who require rehabilitation. Participation by practitioners, managers, patients and caregivers will provide diverse insights into the unique role that community hospitals offer in urban and in rural systems.

Approach
Introduction to the workshop (5 minutes)
Chair outlines the collaborative work to date by SIG members and welcomes the new CH network.

Presentations (45 minutes)
Three speakers describe the policy and practice context for CH in the UK, Catalunya and Malta.
The UK Community Hospitals Association will share evidence from their work with University of Birmingham which demonstrates how much patients value community hospitals and how well embedded these hospitals are within their communities, connecting with many voluntary groups and community organisations. Innovation and good practice examples will be shared and opportunities for delegates to connect with online resources.

Catalunya is reviewing its regional policy to expand intermediate care, building on a strong research foundation in Barcelona. The presentation will compare community hospitals in urban and rural areas, consider how to plan the required intermediate care capacity for population need and discuss the balance between bed based and community based capacity.

Malta is developing integrated care for older persons with frailty through a Transforming Together programme. One new initiative is a dedicated intermediate care unit, co-located at St Vincent de Paul long term care facility, initially targeting patients from care homes as an alternative to emergency admission to acute hospital. The presentation will describe the planning and workforce development to introduce this service, patient and carer experience and outcomes, and describe a novel Rehab decision support tool to help direct flow in future.

Interactive discussion (40 minutes)
Delegates will be invited to share policy and practice examples and patient / carer experience from CH in their context. They will be encouraged to identify gaps in knowledge that may be addressed by the SIG over the next year. Feedback of key points and actions from the groups

Outcomes
The session will conclude with take home messages and agreed actions for the SIG and network to take forward over the next year. A flash report will be circulated after the conference.