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SJHC / Client Services/ Integrated Comprehensive Care (ICC)

Integrated Comprehensive Care (ICC)

What this program does...

St. Joseph’s Health System is engaged in a pilot project called the Integrated Comprehensive Care (ICC) Project. ICC is an innovative patient centered model of care that directly integrates hospital and community care services for patients. The program is designed to make points of transition in care seamless and less confusing for patients and their families. There are two branches of ICC, one in HNHB LHIN and one in WW LHIN. In HNHB, we provide care to patients who have received a hip or knee replacement, are undergoing surgery for lung cancer, or who have chronic disease such as Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF).  In WW LHIN, we provide care to patients who have had cardiovascular surgery, surgery for lung cancer or who have COPD or CHF. This pioneering model, new and unique to the St. Joseph’s Health System, enables health care providers to communicate with each other more effectively resulting in better outcomes for patients.

Integrated Comprehensive Care (ICC) means there is no hand off as patients transition from one part of the health system to another. When a patient moves between hospital to home, the same care team remains in place to ensure there is a continuity of care and support. The Integrated Care Coordinator is a key person in this model of care. This individual helps the patient navigate through every step of their journey, in the hospital and the community. Planning for care in the home after discharge from hospital starts before the patient arrives for their surgery.

Patients in the program are supported by a tight network of healthcare providers located in the hospital and the community. Patients or family members can access the team on a 24/7 basis at any time during their care, by calling a central contact number. The innovative aspect about 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, as well as 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, physicians, physiotherapists, occupational therapists, respiratory therapists, social workers, dietitians and speech and language pathologists. We can very safely transfer care from the hospital to more cost-effective care providers in the community because they are directly connected to a very knowledgeable team.

To watch different patient stories and how this program has made an impact in their life, click on any of the videos below: 

How this program helps...

By reducing the unnecessary barriers to receiving the right care in the right place, we are proving that this is a more cost effective and efficient way of delivering care. We’ve been able to significantly reduce the amount of time spent in hospital, which is the most expensive place to receive care, and deliver more care in the home. The ongoing support provided by the ICC team helps to reduce the number of Emergency Department visits after discharge from hospital, as well as reducing the number of re-admissions to hospital. Above all, our patients are very satisfied with the care they receive – they feel very well supported and are much less anxious about being discharged home from the hospital.

The ICC is the consistent point of contact for patients and their families and they understand the specific needs of each patient in order to better coordinate the health care providers in the community to meet those needs.

Your Care Team

Your St. Joseph's Healthcare Hamilton ICC Care Team:

Donna Johnson - Project Lead
Josie Knox - Integrated Care Coordinator 
Jennifer Swant - Integrated Care Coordinator
Anna Tran - Integrated Care Coordinator
Deborah Little - Administrative/Research Support
Angela Batelic - Program Administrator

Your WWLHIN Care Team:

Sabrina Martin - Project Lead
Alisa Pangehel - Integrated Care Coordinator
Charleene Fros - Integrated Care Coordinator
Brenda Jacob - Administrative/Research Support


St. Joseph’s Home Care
1550 Upper James Street, Suite 201, Hamilton

Referral Process

Patients who are having elective total hip or knee replacement will be referred to ICCP prior to surgery and will meet the Integrated Care Coordinator (ICC) at their pre-op class.  Patients who are having thoracic or cardiovascular surgery will meet the ICC either prior to surgery, or one or two days after their surgery. Patients with Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF) will be referred by the health care team while in the hospital. The ICC will coordinate transitions of care throughout the patients’ journey from the hospital to the community.

Additional Resources

Please visit to learn more about the ICC pilot program.

Please click here to download the Integrated Comprehensive Care Project Brochure.