Integrated Care Pathways help people with COPD and heart failure stay healthier, longer
April 16, 2025.
For people living with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), having a primary care provider (family doctor or nurse practitioner) can make all the difference. Without one, they are at greater risk of worsening health and repeat visits to the emergency department. Yet in many cases, many of these individuals are not connected to a primary care practitioner.
Recognizing this gap, the Frontenac, Lennox and Addington Ontario Health Team (FLA OHT) set out to find and support these individuals through a new initiative focused on connection and care.
Finding and connecting high-risk individuals
A dedicated team working on Integrated Care Pathways (ICPs) —coordinated care plans that bring health and community providers together—started regularly reviewing emergency department data. Through this work, led by an interdisciplinary ICP team from Kingston Health Sciences Centre, high-risk patients without a primary care provider were identified.
From there, the ICP team partnered with community organizations like Kingston Community Health Centres (KCHC) to connect patients to ongoing primary care.
The Unattached Patients Initiative: A new connection to care
This work led to the creation of the Unattached Patients Initiative. Community members identified through emergency department reviews are matched with Dr. Ani Garg, a family physician at KCHC and the Primary Care Lead for the Integrated Care Pathway. Dr. Garg committed to accepting 100 of these high-risk individuals into his practice—and already, 49 people have been connected to ongoing care this year.
Dr. Garg’s motivation for taking on these folks is simple. “My decision stems from recognizing a critical gap in care continuity for these high-risk patients,” shared Dr. Garg. “Many individuals with COPD and heart failure struggle to access timely primary care after hospitalization, leading to preventable readmissions and worsening health. By accepting these patients, I aim to bridge that transition, ensuring they receive consistent, proactive management rather than relying on episodic emergency care.”
The importance of access to primary care
The weeks after a hospital stay are crucial—with the right support, these individuals can avoid going back to the hospital. Primary care teams like Dr. Garg’s monitor symptoms, adjust medications, and connect patients to services like smoking cessation and vaccinations.
The role of primary care is not only critical to the ongoing health management and wellbeing of these individuals, but has systems-level benefits for the entire health-care landscape. Research shows that people with COPD or heart failure who have a primary care provider experience up to 40 per cent fewer hospitalizations. It’s better for people—and better for the entire health system. “Primary care—with its focus on continuity, prevention, and complexity—can help solve some of health care’s toughest challenges: reducing wait times, lowering costs, and delivering equitable care,” explains Dr. Garg.
Caring for the whole person
At KCHC, Dr. Garg and his team take a holistic approach to care, addressing not only medical needs but also social determinants of health like housing, food security, and transportation challenges. Same-day urgent visits, strong partnerships with hospitals and specialists, and a focus on prevention are all part of their model. “This adapted model showcases primary care’s specialty in managing complexity,” explained Dr. Garg “We don’t just treat diseases, we care for whole persons in their context [of their lives].”
Dr. Aws Almufleh, a cardiologist at KHSC and the Specialist Lead for the Heart Failure Pathway within the FLA OHT Integrated Care Pathways, has seen the impact firsthand. “I cannot describe the joy my unattached patients had when I informed them that I have a skilled primary care provider who is ready to take over their care,” he said. “Dr. Ani Garg’s care has enabled us to discharge stable heart failure patients from the [Heart Function] Clinic, which improved our capacity to see new consultations and more complex patients. This collaboration has been incredibly rewarding!”
Building a better system
Integrated Care Pathways–and new innovations like the Unattached Patients Initiative–are helping ensure no one falls through the cracks. They aim to reduce hospitalizations, prevent complications, and support people living healthier lives.
The FLA OHT is tracking how these new models of care are making a difference. Community member feedback, health outcomes, and hospital visit data are all part of an ongoing evaluation that will help shape future improvements. The goal is to deliver seamless, compassionate, and evidence-based care that meets people where they are—and keeps them healthier, longer.