Home is Where the Health Is: Dramatic results show shifting chronic disease care closer to home reduces hospital use

by Nadine Morris | Jan 23, 2018

Ottawa, Canada – January 23, 2018 –  According to the Canadian Foundation for Healthcare Improvement (CFHI), new results from an initiative moving chronic care from the hospital to the home could have a transformational impact on the sustainability of healthcare. New results from health systems participating in the INSPIRED collaboration show that providing the right services to support Canadians with chronic obstructive pulmonary disease (COPD) in their homes has improved quality of life for patients, while also dramatically reducing hospital readmissions by 64% and emergency department visits by 52%.

“Too often, people with chronic diseases like COPD end up in hospital because the care they need is not available in the community,” says Maureen O’Neil, President, CFHI. “INSPIRED provides the services patients and their families tell us they need to manage their disease outside of hospital and now we are expanding this innovative collaboration to benefit more patients.”

Dramatic Improvements

These latest results show how INSPIRED’s hospital-to-home model resulted in a sustainable reduction in the number of emergency department visits and hospital readmissions among more than 2000 patients with COPD, since the program was implemented in 2014-15.



“These results are important because they show we can keep people with chronic disease out of the hospital by partnering with them to reinvent the way we deliver care so it meets their needs,” says Maria Judd, Vice President of Programs at CFHI. “All Canadians who use and pay for the healthcare system, not just those with a chronic disease, will benefit from the emergency department and hospital bed capacity this approach will free up as it spreads across the country.”

New Teams Announced

Based on their success in the first phase of the INSPIRED collaboration and their potential to reach more people with COPD, CFHI has selected six teams from across the country for the next phase of this multi-year effort:

  • Alberta Health Services (Edmonton Zone)
  • Manitoba (including Winnipeg Regional Health Authority, Interlake-Eastern Regional Health Authority and Prairie Mountain Health)
  • Joseph Brant Hospital and Caroline Family Health Team (Burlington, Oakville and Hamilton, Ontario)
  • Horizon Health Network (New Brunswick)
  • Nova Scotia Health Authority (NSHA)
  • Health PEI

CFHI is providing a total of $1.4 million in funding and significant support to scale up existing INSPIRED programs to more providers, sites and patients. The teams are coalitions of hospitals and health regions/systems, primary care organizations and community partners that have come together to better meet the needs of people with COPD.

The Goal: Benefit More Canadians

Participating in this collaboration, these teams estimate they will reach an additional 2300 people living with advanced COPD across up to 39 hospitals and 13 primary care organizations by March 2019. The ultimate goal is to continue expanding until all patients who could benefit from INSPIRED have access to the program.

Third-party analysis has shown that expanding this program to reach 5,800 patients annually by 2021 could prevent nearly 70,000 emergency department visits and 400,000 hospital bed days, avoiding $688 million in acute care costs. For every dollar invested in INSPIRED, $21 in hospital-based costs could be prevented.

A deadly, prevalent, and costly chronic disease

Of the chronic diseases, COPD is the number one reason for hospitalizations in Canada, accounting for the largest number of hospital admissions from emergency departments and hospital readmissions. COPD is a chronic and progressive lung disease that includes chronic bronchitis and emphysema, and is characterized by uncomfortable breathing that worsens over time. A conservative estimate finds that about 800,000 Canadians live with COPD and people with advanced COPD are among the highest users of Canada’s hospital resources. One in four Canadians (25 percent) is expected to develop the disease in their lifetime, meaning the impact of COPD will worsen in the coming years unless we begin to meet more of the needs of people with COPD and other chronic diseases outside of hospital.


INSPIRED enhances patient confidence to manage their illness more effectively in their homes and communities. The program was first developed by Dr. Graeme Rocker and two colleagues, a respiratory therapist and a spiritual care practitioner, at Capital Health in Halifax (now part of the Nova Scotia Health Authority) based on extensive input from patients and their caregivers.

Healthcare teams identify patients who visit emergency departments or are hospitalized with advanced COPD, and invite them into a supportive program that equips them to better manage their illness by providing them with: written action plans for managing their disease; phone calls after they are discharged home and at later intervals; at-home self-management education and psychosocial support; and advance care planning when needed. Patients in the program are also given a day-time telephone number to call for support.

“The more you know, the more control and the less stress you have,” says Charlotte Starratt, the wife and caregiver of INSPIRED patient Wilbur Starratt of Sackville, Nova Scotia. “The questions we’re able to ask and are encouraged to ask is a big thing. It’s about getting control of a whole new way of life.”


Right now, Canadians, their governments and healthcare organizations are looking for ways to advance the shared priority of enhancing home and community care. Many are focusing on scaling evidence-based models that reduce the number of patients in hospital who could be better cared for at home or in the community. CFHI is offering its support and we encourage others to join us in making change happen.

B-roll Download link

CFHI Website: www.cfhi-fcass.ca/INSPIRED 

RiskAnalytica Report 

Regional Backgrounders:
Atlantic Canada
Western Canada

About CFHI
The Canadian Foundation for Healthcare Improvement identifies proven innovations and accelerates their spread across Canada, improving patient care, the health of Canadians and value-for-money. CFHI is a not-for-profit organization funded by Health Canada. Visit cfhi-fcass.ca for more information.

The views expressed herein do not necessarily represent the views of Health Canada.

For more information, or to arrange media interviews, please contact:

  • Elissa Freeman – 416-565-5605
  • Robyn McIsaac (Atlantic Canada) – 902-440-1551
  • Holly Roy (Western Canada) – 780-991-2323