Integrated Comprehensive Care Project

Integrated Comprehensive Care - Bundled Care

St. Joseph’s Health System is engaged in a one year program to demonstrate an innovative model of care that directly integrates hospital and community care services for patients. St. Joseph’s Healthcare, Hamilton and St. Joseph’s Home Care Hamilton (both members of St. Joseph’s Health System), are collaborating on this important initiative. We are providing care for patients who have received a hip or knee replacement, are undergoing surgery for lung cancer and patients who are struggling with a chronic disease.

Integrated Comprehensive Care (ICC) means the patient isn’t being handed off from one part of the system to the other; the patient moves to a different environment, their home, but the team remains the same. The Integrated Care Coordinator is a key person in this model of care; they help the patient navigate through every step of their journey, in the hospital and the community. Planning for home care after discharge from hospital starts before the patient arrives for their surgery.

The patients are supported by a tight network of healthcare providers, who are located in the hospital and the community. The patient or family members can access the team on 24/7 basis at any time during their care, by calling a central contact number. The innovative aspect about Integrated Comprehensive Care (ICC) is that we’ve used very simple, inexpensive technology to deliver care, using tablet computers to maintain an electronic health record and communicate with the health care team and the patients/families in the home. Reaching another team member is only a phone call, Skype call or email away, and each team member is accountable to work with the patient and other members of the team. 

Members of the ICC team have access to a wealth of expertise, such as nurses, surgeons and physiotherapists. This allows us the team to work to their full level of training. We can very safely transfer care from expensive and sometimes scarce professional services to more cost-effective care providers because they are directly connected to a very knowledgeable team. 

By reducing the unnecessary barriers to receiving the right care in the right place, we are proving that this is faster, cheaper, better way of delivering care. We’ve been able to significantly reduce the amount of time spent in hospital after surgery, which is the most expensive place to receive care, and deliver more care in the home, all while reducing the number of emergency visits after discharge from hospital. Above all, our patients are very satisfied with the care they have received and feel they are very well supported and are much less anxious about being discharged home from the hospital.

Click here to download the Integrated Comprehensive Care Project Brochure, Project Summary & Interim Results, February 2013