What this program does...

The Integrated Comprehensive Care (ICC) program 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. This pioneering model, designed by the St. Joseph’s Health System enables health care providers to communicate with each other more effectively resulting in better outcomes for patients.

To learn more about ICC watch our short videos below:

At St. Joseph’s Home Care, we provide care to patients who have received a hip or knee replacement, are undergoing surgery for a variety of reasons such as lung cancer, kidney transplant, gastrointestinal issues or who have chronic disease such as Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF). In addition, we also care for patients who require peritoneal dialysis at home.

How this program helps...

ICC means the patient isn’t being handed off from one part of the system to the other; when the patient moves to a different environment, i.e. their home, the same care team remains in place to ensure there is a continuity of care and support.

One Person To Coordinate Care
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 home care after discharge from hospital starts before the patient arrives for their surgery.

24/7 Access To Care
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 and 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.

A Wealth Of Expertise
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.

Proven Results
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, all while reducing the number of emergency visits after discharge from 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.

Contact

St. Joseph’s Home Care
170 Ogilvie St Dundas, Ontario L9H 0C6
905-522-6887 or 1-877-611-0669

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 click here to download the Integrated Comprehensive Care Project Brochure.