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Neighbourhood Integrated Care Team Pathway Planning and Development Update

As part of our Neighbourhood Integrated Care Team Project, members have been working closely with Optimus SBR Consulting to develop Integrated Care Pathways. Integrated care pathways are structured multidisciplinary approaches to providing care that detail essential steps in the care of patients with a specific clinical problem. They, include both clinical and navigation care elements, and involve more than one organization’s services/programs/resources. These pathways are a crucial component of our integrated care team model, which aims to enhance access to healthcare services while improving patient and provider experience. This approach supports a population health management perspective.


Through this process, we have identified three refined target populations. These include;

  • Seniors with congestive heart failure transitioning from hospital to home

  • Youth transitioning to adult mental health services

  • Newcomers accessing diabetes education and care.

Furthermore, these workshops have included co-designing each pathway, with a primary focus on the three key stages of intake, triage, and assessment. The co-design process has been instrumental in helping us develop care pathways that are tailored to the unique needs of each target population. We are confident that the implementation of these care pathways will improve the quality of care provided to residents of KW4.


As we move forward, we will continue to refine and enhance our care pathways, with a focus on care planning, delivery, and validation of the developed pathways. Our goal is to ensure that our residents receive the best possible care and support, and we are committed to achieving this through our integrated care team model and the implementation of our care pathways.




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