From Condition-Based Pathways to Population Health: Why Advancing the Continuum of Integrated Care Matters Now

What happens when partners set out to advance integrated care together without a shared understanding of what progress and outcomes look like? Good work can move in many directions at once, and our efforts can end up working at cross purposes.

In our work with partners across Canada and internationally, we often sit at tables where everyone has said yes to integrated care.

A hospital leader may be thinking about a smoother transition home after surgery. A primary care leader may be thinking about the people in her practice living with several chronic conditions at once. A municipal partner may be thinking about housing, food security and social connection across a whole community. People with lived experience and their caregivers are hoping that this time, the system will come together around them.

Each of these perspectives is true, and each is integrated care. Each also involves different partners, different timelines, different funding arrangements and a different kind of leadership. When these differences go unnamed, partners can find themselves working hard toward goals they have never fully agreed on.

This is where language and shared meaning matter. When many interest holders see integrated care in their own way, the opportunity is to build a shared understanding and a collective way to make sense of how we advance transformation together.

This is why we are delighted to share and highlight a new Healthcare Quarterly article that offers this shared language, A Framework for Sensemaking and Advancing the Continuum of Integrated Care: From Condition-Based Pathways to Population Health, by Jodeme Goldhar and Dr. Anne Wojtak.¹

Jodeme is the Founder and CEO of the Centre for Systems Collaboration, co-director of IFIC Canada and of the North American Centre for Integrated Care, Knowledge Mobilization Lead for the Network for Integrated Care Excellence (NICE) and the co-director for the National Health Fellows and Collaborative Health Governance Programs at the Health Leadership Academy.

Anne is co-lead of East Toronto Health Partners (Ontario Health Team), co-editor-in-chief of Healthcare Quarterly and an adjunct professor at the Dalla Lana School of Public Health, University of Toronto.

The article starts from an important premise. Integration of health and social care is best understood as a continuum of approaches, and understanding it this way helps health system leaders, clinicians, policy makers and researchers, in partnership with people with lived experience and their caregivers, align their strategies with local needs and advance toward a long-term vision for population health and equity.

Three approaches along the continuum

The framework describes three approaches to integrated care as distinct but interconnected:

• Condition-based integrated care focuses on defined patient groups using standardized clinical pathways, such as hip and knee replacement or stroke rehabilitation, and requires limited coordination.

• Multi-condition integrated care supports people living with complex chronic conditions and requires comprehensive, multi-sectoral coordination and interconnected structures.

• Population-based integrated care organizes health and social care around community needs and the social determinants of health, and requires system-level governance with aligned policy and funding.

Figure 1. Complexity versus impact across the continuum of integrated care. Reproduced from Wojtak and Goldhar, Healthcare Quarterly 28(4), 2026 (Figure 3).¹

The figure places the three approaches against two axes: degree of complexity and degree of impact. Both rise as integration broadens from one patient group to whole communities. The three arrows along its base show what increases at each step: the intensity of coordination and collaborative partnerships; the focus on wellness, disease prevention and the social determinants of health; and partnership with people with lived experience and community mobilization.

Moving from left to right along the continuum, each stage represents an expansion in purpose, partnership and relational depth. The authors describe six interacting dimensions that deepen at the same time, and the first three run along the base of that figure:

1. The intensity of coordination and collaborative partnerships

2. The focus on wellness, prevention and the social determinants of health

3. Partnership with people with lived experience and community mobilization

4. Payment systems and funding alignment

5. The degree of adaptability, complexity and impact

6. System governance and adaptive leadership

“Ultimately, not all integrated care leads directly to population health improvement, but population health cannot be advanced without integration.”

Anne Wojtak and Jodeme Goldhar
Healthcare Quarterly, Vol. 28 No. 4, 2026

What this means for those leading transformation

Whether you are leading a transformation office, an Ontario Health Team, a regional partnership or a community collaborative, the framework offers a way to make strategic choices with intention. It invites leaders to align the chosen approach to integrated care with the intended goals, so that collective efforts are fit for purpose.

Naming where we are

A shared language for the work.

When partners can see where their shared work sits on the continuum, they can have an honest conversation about purpose, design, implementation and how success will be evaluated.

Aligning the enabling conditions

Ambition and enabling conditions evolve together.

As the work moves along the continuum, the enabling conditions deepen together. They begin with sustained investment in co-design with people and their families, so partners understand what matters most to them and reorient their organizations together toward it. That shared orientation creates interorganizational and intersectoral interdependence, and funding and governance then follow it.

Holding a layered strategy

The approaches are not mutually exclusive or sequential.

Working across more than one approach helps systems realize shorter term gains while creating the necessary conditions to advance population health over the longer term.

Honouring time and trust

Time and trust are non-negotiable.

As complexity increases, so does the time required, in some cases years or decades. Population-based integration requires patience, persistence and partnership with people, families and communities.

Evolving leadership and governance

Leadership and governance grow with the work.

Distributed leadership and shared governance build collective capability, the shared capacity of organizations, sectors and communities to lead, learn and adapt in pursuit of common goals.

When leadership and governance advance in concert, integrated care becomes an enabling architecture for population health, organized around collective stewardship, equity and resilience.

Leadership capabilities that are fit for purpose

The framework, alongside the International Foundation for Integrated Care's Nine Pillars of Integrated Care, describes what integrated care requires.² How these elements are enacted in practice depends on the development of core competencies that enable large scale change.

Advancing along the continuum is structural and programmatic work, and it also requires strategic, relational and adaptive capabilities that allow systems to work in interdependent ways. Depending on context, the authors describe these as the ability to:

• build and sustain trust;

• share power across organizational boundaries;

• lead strategically and collectively;

• create safety for learning and unlearning, to enable growth and impact together; and

• steward complexity through reflection and adaptation.

These are the impact at scale skills that enable the shift along the continuum. Without them, efforts to integrate care can take on the form of integration while the work itself remains transactional.

“Advancing along the continuum demands both strategic intent and sustained investment in the social architecture of collaboration. Trust, co-design and continuous learning are as essential as policy alignment or funding reform.”

Jodeme Goldhar and Anne Wojtak
Healthcare Quarterly, Vol. 28 No. 4, 2026

This is at the heart of the work of the Centre. These capabilities are deeply connected to the fourteen shifts in our series, Mindset and Behaviour Shifts for Our Possible Future, including the move from transactional to relational, from old power to new power and from independent to interdependent.³

In this issue of Healthcare Quarterly, the authors focus explicitly on the how, articulating the core capabilities and enabling conditions that allow integrated care to move from intent to enduring practice.

Key messages

• Integrated care is best understood as a continuum, from condition-based pathways to population-based integration.

• As integration broadens, complexity and adaptive capacity increase, and integration becomes a matter of coherence and aligning diverse actors around shared purpose.

• Partnership with people with lived experience, their families and communities deepens at every step, and lasting solutions come from co-design over time.

• Impact expands from individual to collective, from improving outcomes for some to enabling wellbeing for all.

• Time and trust are non-negotiable.

• Population health and equity depend on an ecosystem approach that integrates health, social and community systems through shared purpose, distributed leadership and collective accountability.

Your invitation

As you read the article, we invite you to hold your own work in mind. Where does your integration work sit on the continuum today, and is that where your goals need it to be?

How are the people and families you serve shaping that work, and are your organizations reorienting together around what matters most to them? Are your funding, governance and leadership arrangements aligned with the approach you have chosen? Which of these capabilities is already strong within your partnership, and which would most change what becomes possible if you invested in it together?

We invite you to read the full article and share it with the partners you are building with.

This is the work we do: holding the space for leaders, teams and communities to make sense of complexity together and to build the relationships and capabilities that are fit for purpose. You can reach us at connection@centreforsystemscollaboration.com.

Connection is the correction.

With gratitude,

The Team at the Centre for Systems Collaboration

Endnotes

1. Anne Wojtak and Jodeme Goldhar, A Framework for Sensemaking and Advancing the Continuum of Integrated Care: From Condition-Based Pathways to Population Health, Healthcare Quarterly 28(4), 2026.

2. International Foundation for Integrated Care, Nine Pillars of Integrated Care.

3. The Centre for Systems Collaboration, Mindset and Behaviour Shifts for Our Possible Future, 2026.