St. Joseph’s Integrated Comprehensive Care Team

St. Joseph's Integrated Comprehensive Care TeamSt. Joseph’s Healthcare Hamilton

The Integrated Comprehensive Care Team (ICCT) at St. Joseph’s Healthcare Hamilton (SJHH) is a joint initiative between two hospitals, a home care agency and community partners. Together, these sectors have developed innovative clinical care pathways that follow patient journeys across hospital and home care.

Integrated Comprehensive Care (ICC) works by taking a patient viewpoint on a hospital service that is characterized by fragmented delivery, and then combining the clinical teams, pathways and patient record into a single platform. The combined clinical team then works together and with patients to redesign care, including such manoeuvers as shifting specific clinical activities to the most effective and lowest cost setting (i.e. from hospital to community or from acute to rehab). ICCT members change their practices to support the patient journey across the two sectors as a single journey, including cross training each other and operating to their full scope of practice. ICC further adds value with 24/7 phone support for the patient, combined with responsive and flexible services.

Always aiming to improve the care pathways they design, the ICCT recently implemented the following changes to their original concept based on patient and family feedback combined with outcomes and cost data:

  • Increased responsiveness to patient and family requests, leading to a reduction in total service through more timely interventions;
  • Using inexpensive technology, including iPads, to communicate with patients and among team members;
  • Empowering patients to self-care; and
  • Cross-training, leading to significant reductions in inpatient care with better outcomes.

The above changes have led to significant improvements in quality, patient/client satisfaction, and cost savings, including reduced costs per medical case. SJHH staff have also reported a greatly improved quality of work life. Most recently, the Ministry of Health and Long Term Care asked the ICCT to coach and mentor new integrated teams as part of a planned development and spread of bundled funding models in Ontario which was announced in 2015.

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