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Representatives from healthcare organizations across the province gathered on January 23, 2020, to learn about St. Joseph’s Health System (SJHS)’s Integrated Comprehensive Care (ICC) program and how evidence-based models of Integrated Care could be applied in their organizations to support their Ontario Health Teams. The event is the first in a series of educational seminars, called Integrated Care Discovery Sessions, that SJHS’s Centre for Integrated Care has launched.

Attendees at the session included healthcare leaders, patient advisors and front-line staff from Kingston Health Sciences Centre, Peterborough Regional Health Centre, Peterborough County/City Paramedics, Peterborough Family Health Team, Mississauga Halton LHIN, and Guelph General Hospital.

Since 2012, St. Joseph’s Health System has pioneered Integrated Care in Ontario in partnership with patients, front line staff, health care delivery partners, as well as the Ministry of Health and local funding bodies. Integrated Comprehensive Care is an evidence-based model of Integrated Care that supports patients with One Team, One Record, One Number to Call, 24/7.

ICC is enabled by a co-designed integrated service delivery model and an integrated funding model, which we refer to as One Fund. Our focus is to make the patient experience as seamless as possible while utilizing existing resources across the healthcare continuum, to deliver an integrated and comprehensive care experience. ICC is sustainable, transformational system change enabled by evidence-based integrated service delivery and funding model.

“With over 17,000 patients served to date through the ICC program and savings of up to $4,000 per patient, it is essential to share practical advice on how to replicate this success. To date, we have coached over 30 organizations and continue to be the resource for our health system colleagues seeking advice and support on how to implement integrated care,” says Fraser Edward, Vice President, Partnerships and Business Development, St. Joseph’s Health System. “These Integrated Care Discovery Sessions are a great way for us to share key learnings with other healthcare leaders, patient advisors and frontline staff; and provide a platform for discussion and collaboration.”

The session took place at St. Joseph’s Healthcare Hamilton, in partnership with St. Joseph’s Home Care with speakers including ICC coordinators, clinical programs, finance, digital solutions and our front-line home care team. Our group shared the knowledge gained from their practical experience launching and working with this model.

Topics included how to establish a foundation of trust through co-designing care paths with patients, staff and physicians; the role digital health technology play in Integrate Care; and how to build and manage an Integrated Funding model. The session also included a virtual visit demonstration with ICC patient ‘Georgia’ and the opportunity to hear her perspective on the impact of the program.

Throughout 2020, monthly Integrated Care Discovery Sessions will be held at St Joseph’s Healthcare Hamilton, open to healthcare organizations interested in learning about evidence-based models of Integrated Care.

To secure your spot at the next ICC Discovery Session, please contact:

Fraser Edward
Vice President, Partnerships and Business Development,
St. Joseph’s Health System



Find out more about the ICC program and the Centre for Integrated Care.


The model of bundled care sees different groups of providers band together, share accountability and care for the patient throughout the entire journey.

July 24, 2019 By Joanna Frketich , Grant LaFleche

The Hamilton Spectator and St. Catharines Standard

HAMILTON, ON- JUNE 17- Susan Apro helps her mother Pat Coffer, 94, into bed in Apro’s livingroom where Coffer spends 18-20 hours a day sleeping. Coffer was relatively healthy – gardening and walking – until she started having heart issues in April . It’s hard to guess what the journey of patients like Pat Coffer will look like after the Progressive Conservative’s massive health-care restructuring, but the goal is for it to resemble bundled care. bundled care attempts to bridge the gaps that often leave patients lost by never handing the patient off from one service to another, making life for people like 94-year-old Pat Coffer, a little bit easier.  June 17, 2019. John Rennison/The Spectator

Something as simple as a phone number has made it doable for Susan Apro to care for her 94-year-old mother at home.

Those 10 digits mean help from St. Joseph’s Healthcare is just a call away for the 70-year-old daughter who is taking on the daunting task of caregiver after her fiercely independent mom, Pat Coffer, developed untreatable heart issues and an aneurysm in April that has left her severely debilitated.

“It means the world to me,” said Apro. “For mom to come home, the burden has all fallen on me … I don’t know what the heck I’m doing.”

The trusted voice on the other end of the line can send a nurse or personal support worker to the East-Hamilton house outside of the usual home-care schedule. Another day, Apro could be asked to send a picture of an emerging bed sore to get instructions on what to do.

“I didn’t have to scramble to get anyone to come into the home,” said Apro. “We can call this number any time.”

Never having to navigate the health-care system alone is the foundation of the highly successful pilot program called bundled care or integrated comprehensive care, introduced by St. Joseph’s in 2012.

“My mom made me promise that she would never go in a nursing home, so as long as I’m able, I’ll keep my mom home, looking after her,” said Apro. “With this program, I have that support behind me.”

It’s hard to guess what a patient’s journey will look like after the Progressive Conservative’s massive health-care restructuring, but the goal is for it to resemble bundled care.

“It is a highly respected model that this plan mimics,” says Donna Skelly, Conservative MPP for Flamborough—Glanbrook. “It has been very successful in Hamilton. It’s a model that we are, in essence, replicating with this new approach to health-care delivery.”

The health-system revamp came into effect June 6 under the Connecting Care Act. An investigation by The St. Catharines Standard and The Hamilton Spectator provides the most comprehensive coverage to date of the overhaul, considered the biggest change since Medicare.

The plan, announced in February, puts a super agency named Ontario Health in charge of the entire health-care system — from hospitals to community care to organ donation to cancer care. It will oversee dozens of regional groups, called Ontario Health Teams, made up primarily of health and social service organizations working together to integrate services locally and help area residents navigate the system.

As the Conservatives undo many of the previous governments’ health-care reforms, primarily local health integration networks (LHINS), there is some irony that a program championed by the Liberals is the prototype for the latest round of health-care restructuring.

Similar to the planned Ontario Health Teams, the bundled care model sees different groups of providers band together, share accountability and care for the patient through the entire journey. There is one pot of money split between all the services, increased use of technology and a navigator to guide patients’ through the system.

“Even family docs have trouble navigating the system,” said Dr. Tom Stewart, CEO of St. Joseph’s and Niagara Health. “We need to make it easier.”

Stewart himself admits he was worried when his father’s lung cancer surgery was scheduled on a Friday at the Hamilton hospital he now leads.

“You’re always a little nervous sending people home on Friday because you’re not sure their home-care team is going to show,” he said. “There is not that point of accountability. It’s a fragmented system.”

Bundled care attempts to bridge the gaps that often leave patients lost by never handing the patient off from one service to another.

Planning starts at admission — or even before for scheduled procedures — so services needed, both in and out of hospital, are pre-arranged and ready to go when needed.

Discharge is not when the patient leaves the hospital but roughly 60 days after going home with one team of providers responsible for the patient’s care from start to finish. The team could include doctors, nurses, physiotherapists, occupational therapists, social workers, dietitians, respiratory therapists, speech and language pathologists and personal support workers. Ideally, the patient meets as much of the team as possible before leaving the hospital.

Most important, there is one point of contact called a care co-ordinator who arranges what’s needed, oversees the care and helps the patient navigate the system.

“We would refer and set up all their services at home,” said Heather Paterson, Niagara Health’s chief nursing officer and director of patient care. “Our care co-ordinator follows (the patient) from hospital to home.”

Patients get a number to call 24-7 where co-ordinators are on standby to stick handle any issues.

Members of the team, such as specialists, can be accessed through technology, which is the type of “virtual visit” recommended by the Premier’s Council on Improving Health Care and Ending Hallway Medicine in its June report as a way to cope with the increasing demands of an aging population.

Stewart’s dad was able to get immediate answers from his doctors without leaving home when there were potential issues with his surgical wound.

“I’m a doctor, and I would have quite honestly said, ‘Go back to emerg,'” said Stewart. “He ends up calling a number and sending a picture of the wound from home with technology, and the doctors say, ‘This is normal. Don’t worry about it.’ That prevents an emerg admission, so you can see how you can start to improve the system.”

Stewart says the program’s three major pillars are one multidisciplinary team, one medical record and one number for patients to call.

The program now stretches from Niagara to Kitchener and has expanded to include chronic lung disease, congestive heart failure, lung cancer surgery, hip and knee replacements, peritoneal dialysis and mental health and addictions. In the fiscal year that started April 1, it is expected to expand to all patients undergoing planned and scheduled surgeries at St. Joseph’s.

So far, 17,000 area patients have received bundled care. Its success was highlighted by the Premier’s Council. Its June report states the program reduced length of hospital stay by 1.26 days on average, reduced costs within 30 days by $2,110 and within 90 days by $3,035.

In addition, 87 per cent of surveyed patients said they felt they were involved and informed in their care.

“The vast majority are saying it’s way better,” said Stewart. “The health-care workers are happier and home-care workers are telling us they feel they can get a nurse or doctor at the hospital easier now, and they feel part of the same team. Caregivers, the patients and their families are a lot more happy.”

St. Joseph’s reports up to a 30-per-cent reduction in emergency visits and hospital readmission rates

At Niagara Health, the readmission rate has fallen to 15 per cent from 19 per cent three years ago, when the program started. The number of patients having to visit the emergency room after discharge also fell over the same period to 32 per cent from 38 per cent.

“By offering the support and building capacity in the community, we are able to manage patients and give them access to care they might not have had,” Paterson said.

It was a lifeline for Apro after her active mom went from gardening and walking to spending most of her time in bed.

She wouldn’t have known where to turn if the program hadn’t arranged for a hospital bed, walker and commode chair to be sent to her house so her mom could live on the main floor. Making it more difficult is that Coffer hasn’t had a family doctor since hers retired.

“My mom has never been sick, and all of a sudden, she’s got these heart issues and she can’t even wash herself,” said Apro. “It’s very upsetting, and it’s a lot of work to take on, but I wouldn’t let anyone else do it.”

The program isn’t perfect. Its major weakness is primary care isn’t involved at all, leaving patients vulnerable after discharge from bundled care.

“There’s got to be that hand off,” said Dr. David Price, head of family medicine at McMaster University. “If you don’t integrate that then they fall through the cracks.”

Bundled care is also too narrow in scope, says Rob MacIsaac president and CEO of Hamilton Health Sciences.

“From my perspective, it doesn’t make a lot of sense to limit it to certain patient populations that are defined by their illnesses,” he said. “I think it would be much better if we could open it up.”

Under Ontario Health Teams, this model would significantly expand to eventually cover all patients and not just those transitioning from hospital to home.

“It will improve patient care by connecting care,” Health Minister Christine Elliott said on a July 18 conference call with health care workers. “People are discharged from hospital, and those people feel like they are shut out of their own health care system and have to fight their way back in.”

She said patients need to know their after-hospital care will continue at home, know how that care works and when and how they can access it.

Even the CEO of the regional network being dismantled by the restructuring thinks patients will be better off in the end.

“While we know these proposed changes will take time, when fully realized, patients, families and caregivers will have access to faster, better and more co-ordinated services,” said Donna Cripps, CEO of the Hamilton Niagara Haldimand Brant LHIN, which includes Burlington.

HAMILTON, ON- JUNE 17- Susan Apro has her mother Pat Coffer, 94, living in her livingroom where Coffer spends 18-20 hours a day sleeping. Coffer was relatively healthy – gardening and walking – until she started having heart issues in April . June 17, 2019. John Rennison/The Spectator

It is expected to take years before the monumental changes envisioned by the Conservatives are in place.

“You just can’t change a system as big as health care on a dime,” said Paul Johnson, who is representing the city in the Hamilton Ontario Health Team application.

The government also has to be careful not to disrupt care during the changes.

“It has a lot of promise but, in the meantime, there are going to be things that have to be done to keep the health system functioning while facing some very serious challenges,” said Anthony Dale, president and CEO of the Ontario Hospital Association.

The Ontario Health Coalition worries those pressing issues, like overcrowded hospitals, inadequate home care and shortages of long-term care, will fall by the wayside during the overhaul.

“The whole attention of the health-care system now has turned to restructuring and will be for years,” said executive director Natalie Mehra. “I fear for how long it is going to take to go through all of this.”

It’s expected the health-care changes will happen so gradually that patients won’t ever see a big bang where suddenly the health-care system is turned on its head.

“You won’t notice much of a difference in the first week or month or even the first six months,” said Price. “I hope when we look back in three to five years, we will see difference.”

For the most part, patients will continue to interact with the health-system as normal.

“The message we’re communicating … is business as usual,” said Dr. Ralph Meyer, vice-president of oncology and palliative care at HHS and regional vice-president of Cancer Care Ontario. “We’ll evolve as the system evolves.”

The LHIN says its continuing to do the same work it has always done, even as its board has been dismantled and back-office jobs eliminated.

“Home and community care continues as before, and there are no changes to the long-term care home placement,” said Cripps. “People can continue to contact their home- and community-care providers as normal to access the care they need.”

The Canadian Union of Public Employees (CUPE) says the slow change will be hard for health-care workers, particularly in sectors where their roles are expected to dramatically shift.

“For the people who work for the LHINs, nobody knows really what will happen to them,” said Michael Hurley, president of the Ontario Council of Hospital Unions, which is part of CUPE. “They are expected to soldier on; they are not asked for their input, and they are not valued.”

Never having to navigate the health-care system alone is the foundation of the highly successful pilot program called bundled care or integrated comprehensive care, introduced by St. Joseph’s in 2012, which makes it much easier for Susan Apro to care for her mother Pat Coffer. | John Rennison, The Hamilton Spectator

The health-care system is split on how to respond to the changes, with lines drawn between those planning to protest and those hoping to be among the first to adopt the new system.

“We will fight the legislation,” said Mehra. “It’s undemocratic and it’s dangerous.”

The Ontario Health Coalition wants public hearings across the province so Ontarians can have their say.

“The government needs to hear from Ontarians about the real, on-the-ground impacts of what they have created,” said Mehra. “Slow down and listen to people.”

CUPE agrees that the lack of consultation with the public and health-care workers is a top concern.

“I would really appreciate it if this government would stop this process and have a genuine dialogue with people,” said Hurley.

The Ontario Nurses’ Association has started a campaign with the slogan, “Don’t let Doug Ford wreck health care” that urges people to email the premier, the health minister and their MPP.

“This chaotic overhaul of health care is going to take years and cost millions, and there’s no guarantee it will add one single hour of direct care, and it won’t add any of the skilled caregivers who are needed so urgently,” states the campaign.

“The whole attention of the health care system now has turned to restructuring and will be for years. I fear for how long it is going to take to go through all of this,” says Natalie Mehra, the Executive director of Ontario Health Coalition. | Chris Young, The Canadian Press

Unifor had a phone-in town hall for its members about the restructuring and has started a leaflet campaign.

“Wherever we can, we’re going to join in the fight,” said regional director Naureen Rizvi. “People are very angry.

A rally at Queen’s Park April 30 led by the Ontario Health Coalition drew thousands of protesters.

“They’re saying it’s going to be a streamlined system, but I don’t see how they’ve put a model together that actually achieves that,” said Andrea Horwath, Hamilton Centre MPP and leader of the NDP.

On the flip side, Niagara, Hamilton and Burlington health and social service organizations have applied to be early adoptors of the changes by proposing Ontario Health Teams, which are expected to transform the local system. All three groups were informed July 18 that their proposals are moving to the next stage of application.

“In Hamilton, we are in a really good spot to respond to this call,” said family physician leader Price.

Health leaders see it as a logical extension of work that has been going on for years in this area.

“We think we’re ready in Burlington and that we could move forward quite quickly,” said Eric Vandewall, CEO of Joseph Brant Hospital. “We’ve got a lot of enthusiasm around the table and a lot of support for moving forward.”

The province plans to learn from the first Ontario Health Teams to tweak the restructuring as problems are found.

“We have to be looking at these early adopters” said Sue VanderBent, CEO of Hamilton-based Home Care Ontario. “They’re our little petri dish where we try some things and we watch what happens and we learn from that.”

But the experiment really started in Hamilton, with bundled care spreading out over the years to Niagara, Burlington and all of the acute care hospitals in the LHIN and beyond.

“It made a huge difference for me,” said 93-year-old Helen Greves, who got bundled care in February after being released from the Niagara Health cardiac unit in St. Catharines.

While she was part of the program because of her heart condition, bundled care was able to have the flexibility to also look after an unrelated ankle injury from a fall at her Niagara-on-the-Lake home shortly before she went into hospital that has made going out for medical treatment even more difficult.

“Well, at 93 I qualify as elderly, I think,” said Greves. “So I really needed the help.”

Eric Vandewall, CEO of Joseph Brant, says a Burlington mental health partnership has increased access to a wide variety of providers. “We’ve eliminated the feeling patients have about not knowing where to go and being bounced around.” | John Rennison, The Hamilton Spectator


What will your care look like?

No one knows yet exactly what care will look like after the health-care overhaul, but a number of area programs give a potential glimpse of the future.

Joseph Brant Hospital

A Burlington mental health partnership gives patients one point of access to a wide variety of providers so they don’t have to navigate the services on their own. Instead, they are directed to the agency best able to meet their needs.

“Historically we did not operate together,” said Eric Vandewall, CEO of Joseph Brant. “Patients would not know how to access service, which is the right provider, and things were not always timely.”

A second program for chronic obstructive pulmonary disease provides patients with a phone number to call when they need guidance and help navigating the system.

A group for those recovering from hip- and knee-replacement surgery allows patients to do rehab, which would normally be provided at home alone, in a clinic with other patients instead. It’s cheaper, has better outcomes and higher patient satisfaction because it provides peer support and motivation.

“All of this is really about working differently with our community-care providers,” said Vandewall about the various programs. “We’ve increased access, we’ve eliminated the feeling patients have about not knowing where to go and being bounced around, they have timely support, and we’ve been able to reduce wait times significantly.”

Niagara Emergency Medical Services

Non-urgent ambulance calls are visited by Mobile Integrated Health Response Teams in Niagara to connect them with the care they need in the community without going to the hospital.

The teams, made up of EMS and providers in the community, were highlighted in June by the Premier’s Council on Improving Health Care and Ending Hallway Medicine for reducing transports to the emergency department by six per cent for those feeling generally unwell, five per cent for mental health issues and two per cent for falls.

• • •

Operation health care reform: Your guide to the series

The provincial government is undertaking a sweeping overhaul of the health-care system. The changes came into effect June 6 under the Connecting Care Act.

An investigation by The St. Catharines Standard and The Hamilton Spectator provides comprehensive coverage of the health reforms considered the biggest change since Medicare. A four-day, nine-story series looks into all aspects of the plan.

Under the plan, a super agency called Ontario Health will be in charge of the entire system from hospitals to community care to organ transplants to cancer care. It will also oversee dozens of regional groups named Ontario Health Teams that will align health and social service organizations to work together to integrate services and help patients navigate the system.


July 2, 2019 –  Canadian Healthcare Technology

HAMILTON, ONT. – St. Joseph’s Health System (SJHS) is using video visits to connect clinicians with discharged surgical patients at home.

The video-based care builds on St. Joseph’s use of one phone-number access to an integrated care team, around the clock, for discharged patients and provides another dimension of support in their homes.

The video service was launched in January of this year, in conjunction with the Ontario Telemedicine Network (OTN), St. Joseph’s Healthcare Hamilton (Hospital) and St. Joseph’s Home Care, and started with patients discharged from thoracic, hip and knee surgeries.

Once at home, the patients can use computers, tablets or smartphones to interact visually and by voice with a coordinator who is able to answer their questions and can connect them with other members of the care team. Virtual “face-to-face” visits can be scheduled with clinicians, home care nurses, and the patients access these visits through a digital patient portal called MyDovetale.

Since 2012, St. Joseph’s has pioneered a new model of care called Integrated Comprehensive Care (ICC), which gives patients and their families access to One Health Team, One Digital Record, and One Number to Call, 24/7.

Patients first meet their ICC coordinator while in hospital, to receive discharge information, learn about the ICC program and support they will receive at home. Once the patient is in the community, the ICC team uses ‘virtual rounds’ to discuss patients and their care plan together.

Everyone is in the loop and patients don’t repeat their information every time.

“We’re the first Hospital in Ontario to use integrated virtual care software, outside of the Ontario Telemedicine Network OTNhub, to support our patients,” said Andriana Lukich, program manager.

The video service is integrated with the hospital’s new Epic information system (branded as Dovetale), so that clinical records, including diagnostic images and lab test results, can be pulled up and shared while the meeting is going on.

Clinicians can write notes and update the records while they’re conducting the video encounters. The proof of concept is now being expanded to new patient populations at St Joseph’s and has paved the way for OTN’s new Partner Video Project initiative, Lukich said.

The pilot project discovered that virtual visits are not for everyone. Some patients struggled with the technology, and small factors like lighting and avoiding the mute key on a phone could hinder interactions with clinicians.

For that reason, the standard telephone is available for all patients – it’s still the easiest way to reach the ICC team, any time night or day.

Secure Messaging through the MyDovetale patient portal is also offered.

Lukich and hospital Chief Information Officer Tara Coxon discussed St. Joseph’s virtual care solution at the Technology & the Future of Healthcare conference, held in Hamilton in May.

The ICC program has been further enabled by St. Joseph’s Healthcare Hamilton’s implementation of Epic (Dovetale), which went live at St. Joseph’s in December 2017. At that time, said Coxon, St. Joe’s became a digital hospital and jumped to HIMSS EMRAM Stage 6. “Previous to that, we were at EMRAM 1.2,” she said. “It was an over-night transformation.”

The Epic implementation at St. Joseph’s Healthcare Hamilton was named Dovetale to signify the joining of technology with compassion. The system is helping to smooth out some of the pain points in Ontario’s healthcare system, specifically the hand-offs that occur when patients move from one level of care to another.

In one recent instance, a lung cancer patient who underwent surgery at St. Joseph’s was discharged home to Beamsville, only to discover that his wound seemed abnormal. He was worried it might have become infected.

He contacted his ICC coordinator at St. Joseph’s using the one-number service, and she instigated an ad hoc video visit to view the wound in real-time and determined that the patient should receive care right way.

This was arranged through St. Joseph’s Home Care, and on the same day, a visiting nurse travelled to the patient’s home and changed his wound dressings. She also updated his chart, right on the spot.

St. Joseph’s is making medical records available to the patients themselves through the use of a portal – called MyDovetale. “We were hearing that patients wanted better access to their records and that they wanted their records to be accurate and accessible throughout the system,” said Lukich.

In the summer of 2018, St. Joseph’s went live with the MyDovetale portal, extending it to patients in the mood disorder and kidney transplant clinics.

Patients can access their records on any platform, but it’s been found that smartphones are now the most popular device. Access can be given to family members, loved ones and members of care teams. Lukich said that 88 percent of patients report that MyDovetale has allowed them to take better care of themselves. Meanwhile, the video visit service has saved some patients two to three hours of travel time.

Patients have been asking for enhancements to the MyDovetale solution – in particular, they’d like to see prescription renewals and diagnostic imaging reports made available on the system.

MyDovetale will soon be rolled out to 80,000 more patients – an organization-wide rollout.

According to St. Joseph’s, the ICC program has resulted in a savings of up to $4,000 per patient, a 30 percent reduction in emergency department visits and 30 percent reduction in hospital readmissions with a 98 percent patient satisfaction approval rating. It’s doing this by enabling patients to stay comfortably in their homes, getting the reassurance or care they need without visiting the hospital.

The program has been so successful that Ontario’s health ministry would like to expand it to other healthcare providers.

“Already, St. Joseph’s has coached over 30 other organizations on how they might implement an ICC model of their own,” commented Fraser Edward, VP partnerships at SJHS.

“We have established the Centre for Integrated Care to help support Ontario Health Teams and other healthcare providers wrap physical and virtual care around the needs of patients and their families.” For more information, see: www.sjhs.ca/integratedcare/cic/

St. Joseph’s Health System’s pioneering Integrated Comprehensive Care model for COPD/CHF patients could free up 13,502 hospital days annually across the province: Health System Performance Research Network (HSPRN)

June 27, 2019 – Hamilton, ON – A program pioneered by St. Joseph’s Healthcare Hamilton and St. Joseph’s Home Care, members of St. Joseph’s Health System (SJHS), has the potential to free up more than 13,000 hospitals days and save $24.1M in health care if it were spread across the province, according to a new research report.

Conducted by University of Toronto-affiliated Health System Performance Research Network (HSPRN) the evaluation analyzes six existing healthcare programs in Ontario with the aim of creating seamless transitions from hospital to home care. This is done by integrating care for patients through one team, one number to call 24/7 and one electronic record to support their care and save healthcare dollars – the key principles outlined in the government’s vision for Ontario Health Teams

St. Joseph’s Health System pioneered this model of care when it developed Integrated Comprehensive Care (ICC) in 2012. The MOHLTC later expanded the model to other sites throughout the Province, and SJHS partnered to expand ICC across 12 acute centres in the Hamilton Niagara Haldimand Brant (HNHB) Local Health Integration Network (LHIN) for all Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) patients. SJHS was also brought on board by the MOHLTC to support the provincial roll out. The HSPRN report evaluates this expansion.

The evaluation found that all six programs are having a positive effect on reducing hallway medicine. In particular, the total number of days patients spent in the hospital was reduced by more than 20%, readmissions were also reduced up to 37%, and there was an overall 20% relative reduction in Emergency Department visits. In addition, the report highlights that if the SJHS’ COPD/CHF ICC model was spread provincially to all 18,538 patients in Ontario, estimated annual savings of 13,502 hospital days and $24.1M dollars could be achieved.

“I was surprised at how successful HNHB ICC was at improving the transition of care for people with complex medical conditions,” says Walter Wodchis, Principal Investigator of the report and a Professor at the University of Toronto. “The collaboration they built between hospital and post-acute providers was crucial. I don’t think there has been another program that’s been quite [this] successful internationally.”

“This program was created by a group of nurses, PSW’s and frontline workers from the bottom up,” says Danielle Fox, St. Joseph’s Home Care Nurse. “We were given autonomy and flexibility to do what we needed to provide care to the patients. The one team approach and our focus around continuity of care, building rapport and educating caregivers/families as part of the care team are the keys to its success.”

The report recommends the MOHLTC implement a similar model of care for surgical procedures. Earlier this year, St. Joseph’s Healthcare Hamilton and Niagara Health announced they would be one of the first acute hospitals in Ontario to provide ICC program to all planned surgical patients with virtual care options by the end of 2019.

“The results speak for themselves,” says Dr. Thomas Stewart, President & CEO of St. Joseph’s Health System and CEO of Niagara Health. “We’re breaking down silos and working together with primary care and community partners. By coordinating our patient’s care from hospital to home, we not only see favourable outcomes for our patient’s and caregiver’s health, physically and mentally, but we are contributing to ending hallway medicine by freeing up much-needed beds and resources. It’s a win-win.”

ICC Patient/Caregiver testimonials:

• “It’s a marvellous thing. If there’s any chance that I can continue the program, I would jump at the chance. This team is the best, and I have never had anything like it.”
• “It was excellent. All the people that were involved were great. I wish that I’d known about it sooner.”
• “The ICC program has been an excellent help for me and my husband. It was comforting to know there was someone I could call for answers to any health concerns that might arise. The nurses, physiotherapist and dietitian, were all most pleasant and provided much valuable information to best help my husband, and therefore, me!!”

Quick Facts:

• St. Joseph’s Health System pioneered Integrated Comprehensive Care (ICC) and was the first healthcare initiative in Ontario to show the benefits of an Integrated Care approach between the hospital and the community. To learn more about the ICC Program: https://sjhs.ca/integratedcare/

• St. Joseph’s Home Care is the lead Home Care Agency for the HNHB ICC program. Nurses, PSW’s, Physiotherapists and other frontline staff are educated on caring for specific patient streams within the ICC program. To learn more about St. Joseph’s Home Care: https://www.stjosephshomecare.ca/

• Niagara Health, serving over 450,000 residents, contributes to the highest proportion of patients in the COPD/CHF program across HNHB. To learn more about Niagara Health: https://www.niagarahealth.on.ca/

Project partners:

HNHB Community Care Access Centre, HNHB Local Health Integration Network, HNHB Primary Care lead, Brant Community Healthcare System, Centre de Santé Communautaire, Grand River Community Health Centre, Haldimand War Memorial Hospital, Hamilton Health Sciences, Joseph Brant Hospital, Niagara Falls Community Health Centre, Niagara Health, Norfolk General Hospital, North Hamilton Community Health Centre, ProResp, SE Health, St. Joseph’s Healthcare Hamilton, St. Joseph’s Home Care, VitalAire, West Haldimand General Hospital

About St. Joseph’s Health System

St. Joseph’s Health System is one of the largest healthcare organizations in Canada, and only system in Ontario delivering a full continuum of health care services. Medical and specialty services affect care at all points and include acute care, long-term care, home care, hospice and research & education. SJHS is a globally recognized leader for innovation in models of patient-centred integrated care. St. Joseph’s Health System has a unique partnership with Niagara Health to leverage each organization’s strengths to bring better care to the people in the communities we serve.

About Niagara Health

Niagara Health (NH) is a community-based academic centre with a focus on teaching and learning, research and innovation. We are very proud of our strong partnership with the St. Joseph’s Health System and our academic partners including McMaster University, Brock University and Niagara College. Serving more than 450,000 residents across 12 municipalities making up the Regional Municipality of Niagara, NH is a regional healthcare provider with multiple sites and a growing network of community-based services. The team is made up of more than 4,800 employees, 600 physicians, and 850 volunteers to deliver ‘Extraordinary Caring. Every Person. Every Time’. We provide a wide range of inpatient and outpatient services to residents across Niagara, including Acute Care, Cancer Care, Cardiac Care, Complex Care, Emergency and Urgent Care, Kidney Care, Mental Health and Addictions, Stroke Care, Surgical Care and Long-Term Care.


Article: The Toronto Star | Reporter: Theresa Boyle | March 2, 2019

A week after having part of a cancerous lung removed, Grant Lewis grew concerned that the incision wound on his chest had become infected.

The 54-year-old Beamsville construction worker dug out a phone number he had been given when he was discharged from hospital. Call it any time, day or night, if you run into trouble, he was told.

Lewis dialed the number and was connected to his nurse, Anna Tran, at St. Joseph’s Healthcare in Hamilton. On her advice, he used his mobile phone to snap a photo of the inflamed and seeping lesion, and then emailed it to her.

Almost 40 kilometres away, Tran looked closely at the image on her cellphone. She then forwarded it to the home-care arm of St. Joe’s, along with an email requesting that Lewis be seen that same day for wound care.

Within hours of placing the call, Lewis answered a knock at his front door. It was a visiting nurse. She cleaned his wound, changed the dressing, and then updated his medical record on her tablet computer.

Tran and the rest of Lewis’ care team at St. Joe’s all had access to his electronic medical record. The home-care nurse’s update assured them all he did not have an infection and was recovering well.

This little scenario, which took place in January, provides a glimpse into the future of health care in Ontario, as Health Minister Christine Elliott envisions it.

The sectors have a reputation for being siloed. The weakest parts of the health system are the transfer points between them. Hand-offs can be bumpy and patients can fall between the cracks.

Requisitions for ongoing services don’t always get passed along in a timely fashion. Sometimes it seems like they don’t get passed along at all.

Patients, still feeling unwell, can be left to navigate their own way through the Byzantine health system, which is a world unto itself with a seemingly foreign language full of acronyms and jargon.

Because Ontario is not as far along as it could be when it comes to electronic medical records, it can take days for updates to get transmitted between providers. When care is delayed, patients’ health can deteriorate, families can panic and unnecessary trips can be made to the emergency department.

Elliott told a news conference that the overall intent of her plan is to make the system easier for patients to navigate by “seamlessly” connecting sectors and making greater use of digital tools.

Critics of the government’s plans say they are overkill and are worried that the health system could be destabilized while “radical” changes are made. That has been the experience of other provinces that have gone this route, they note. They argue that this much change is not necessary for the Conservative government to make good on election campaign commitments to end hallway medicine, open more long-term care beds and create more mental health and addiction services.

Following Elliott’s Tuesday announcement, the Star followed up with her office to get a better idea of what her reform plans would look like on the ground. It was suggested we take a look at St. Joseph’s Healthcare in Hamilton, specifically at its Integrated Comprehensive Care (ICC) program in which Lewis was a patient.

The program started as a pilot back in 2012. Known then as the “bundled care” program, it was designed to connect surgical patients with a single team of clinicians who could care for them before, during and after their operations.

To date, more than 17,000 patients have gone through St. Joe’s ICC program. In addition to thoracic surgery patients such as Lewis, they include patients who have had hip and knee replacements, suffered from chronic obstructive pulmonary disease and heart failure, undergone cardiovascular surgery and been on peritoneal dialysis.

It has resulted in a savings of up to $4,000 per patient, a 30 per cent reduction in emergency department visits and 30 per cent reduction in hospital readmissions, a savings of more than 30,000 bed days and an increase in patient satisfaction, according to the hospital.

St. Joe’s is in the process of expanding it to all surgeries and some ER patients. There are plans to further expand it to mental health and long-term care patients, and to frail seniors in their homes.

Elliott would like to see this type of program emulated across the province.

“Patients should be fully supported when returning home from the hospital and be connected to home-care services right away. A connected and co-ordinated system is our vision for a patient-centred health-care system,” she said in a written statement provided to the Star.

“The integrated-care model at St. Joseph’s Healthcare in Hamilton is a prime example of the important work that can be achieved when health care is centred around the patient,” her statement continued.

Lewis said he was very pleased with the care he received. Any concerns he had were immediately addressed and he felt confident he was in good hands, he said in a phone interview.

Best of all, he only had to stay in hospital for three nights, he noted. Assurances of good, ongoing care at home allow for quicker discharges.

“I wanted out. I am much more comfortable and relaxed in my own place,” Lewis explained

He had “virtual” followup appointments with Tran, an ICC co-ordinator and Lewis’ main point of contact in the program. Through Skype and a specially designed app, they could have face-to-face conversations, using cellphones, tablets or laptop computers.

The program has been a success with caregivers such as Lewis’ wife Nancy who said she appreciated the immediacy of it: “When you are in a hospital bed and you need help, you press a call button. That’s what this app is like. Anna Tran, someone with so much knowledge, is right there.”

Watch Dr. Tom Stewart, CEO of St. Joseph’s Health System talk about the Integrated Comprehensive Care program that’s changing how Ontarians are receiving care.