What is Integrated Comprehensive Care?
St. Joseph’s Health System (SJHS) is a leader in pioneering new models of care, including Integrated Comprehensive Care (ICC), which uses a bundled funding model to support a seamless patient transition from the hospital to home/community.
Throughout the patient’s care journey they have access to the same team. This sets patients up for a successful recovery by connecting patients with the home care supports they need before they are discharged, and once at home, they have 24/7 access to a clinician.
ICC program was created by St. Joseph’s Health System. Our system colleagues at St. Joseph’s Healthcare Hamilton, St. Mary’s General Hospital Kitchener and Niagara Health are currently participating in the program. We are the provincial leader and pioneer of this program that’s truly redesigning how care is delivered. We’ve coached over 30 healthcare organizations on adapting and implementing the ICC program.
Watch how the ICC program impacted Maureen’s recovery.
One Number to Call, 24/7 Access to a Clinician
The patient or family members/caregivers can access the ICC team on a 24/7 basis during their care, by calling a central contact number.
Not only does this give patients peace of mind and feel more confident but it also avoids unnecessary emergency department visits and follow-up care can be delivered through a home visit or virtual care.
One Health Care Team
We customize the care team according to the needs of our patients. The patients are supported by a tight network of healthcare providers in the hospital and the community. Every ICC health care team has direct access to variety of specialized clinicians such as nurses, surgeons, physiotherapists, respirologists or dietitians. This allows the team to work to their full level of training. We can 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. 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.
One Electronic Patient Record
The innovative aspect of Integrated Comprehensive Care is that we’re embracing technology to improve the delivery of care. The patient’s health care team has access to one electronic health record, so patients don’t have to repeat themselves with each new provider. Once discharged, patients can connect with an ICC coordinator through virtual chat or messaging and also manage their appointments from the comfort of 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.
St. Joseph’s Healthcare Hamilton (SJHH) is the first hospital in Ontario to offer their patients 24/7 virtual access to their Integrated Comprehensive Care team via the web or mobile app. Physicians, nurses, and care coordinators have the ability to message, schedule appointments securely and have a ‘virtual’ face-to-face appointment with patients enabled by the hospital’s Digital Health Information System (Epic). Video visit technology is integrated within St. Joseph’s Healthcare Hamilton’s patient-centred information solution which allows for clinical documentation within a single record accessible to the whole care team. The clinical team can share information directly within the patient’s chart (e.g. diagnostic images) or write a clinical note during the virtual visit.