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Integrated Comprehensive Care Patient at Home with Registered Nurse

Photo: Danielle Fox RN visits patient Ilene Mulholland at home as part of St. Joseph's Healthcare Hamilton's Integrated Comprehensive Care Program for chronic disease. 

St. Joseph’s Healthcare Hamilton’s model for proactively  improving the patient experience and health outcomes at a lower cost to Ontario’s health care system  has been benchmarked by The Honorable Dr. Eric Hoskins, Minister of Health and Long Term Care as a vision for the future of care delivery in the province of Ontario. During his address at the Empire Club in Toronto yesterday, Dr. Hoskins noted St. Joe’s Integrated Comprehensive Care (ICC) model as a pioneering example of a predictive method that aligns “incentives around the patient’s journey” through the new concept of bundled care.

Currently, a fragmented approach to fee-for-service funding is preventing those within the system from working together to put patients first and approximately 5% of our province’s population consumes two-thirds of our healthcare costs. Dr. Hoskins argues that healthcare should be approached from an alternative vantage point, placing value on access to fast, timely and responsive care to improve patient outcomes while balancing fiscal responsibility. According to Dr Hoskins, this new perspective would look a lot like St. Joseph’s Healthcare Hamilton’s ICC model – a model that makes sure that all healthcare providers who are integral to treating one patient’s condition are “provided and paid together.”

Integrated Comprehensive Care means the patient isn’t being handed off from one part of the system to the other; the patient moves to a different environment, their home, but the team remains the same. High needs consumers of healthcare services are provided with one number to call to access their Care Coordinator 24/7. Through the entire journey, the entire healthcare team from hospital into the community connects using smartphones and telemedicine techniques like Skype calls with nurses in the community on an iPad in the patient’s home.

“Since 2011, St. Joseph’s Healthcare Hamilton has seen huge successes in all three of the ICC streams, including lung cancer surgery, hip and knee replacement surgery and chronic disease,” says Donna Johnson, Integrated Comprehensive Care Project lead at St. Joseph’s Healthcare Hamilton. “The result for patients across the region (including Hamilton, Niagara, Brant, Norfolk, Burlington, Haldimand) is that gaps in care are closed, unnecessary emergency department visits are avoided and patients can feel confident in the cohesive team supporting them 24/7. Testing new streams at our system partner, St. Mary’s Hospital in Kitchener, is also showing positive preliminary results.”

Minister Hoskin’s remarks at the Empire Club are encouraging, says Ms. Johnson. “We believe that we will see similar results if we expand this model to other clinical streams, such as mental health, head and neck surgery and other chronic diseases, so we look forward to further details on the Minister’s vision for bundled care in Ontario.”



Patients First: Action Plan for Health Care| Dr. Eric Hoskins | Ministry of Health and Long Term Care


The Hamilton Spectator | Joanna Frketich | St. Joe's to advise the province on new ways to fund care

CBC Hamilton | John Reiti | Ontario embraces healthcare model tested in Hamilton


AM900CHML | Scott Thompson Show | Wednesday, February 4th at 1:00pm

Share: Twitter: @STJOESHAMILTON | Facebook: St. Joseph's Healthcare and Foundation


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