Niagara Health


Type of Practice


Currently in Ontario, many patients are cared for in hospital and then discharged home with community care supports. From the patient’s perspective, there are two (or more) distinct episodes of care that begin and end at the interface between the hospital and community. An alternative model of patient care is through bundled payment, where a single health care provider may be given a single payment to provide both hospital and the community care for specific patient groups.
St. Joseph Health System (SJHS) developed and implemented the Integrated Comprehensive Care Program (ICC) in 2012. This innovative model, consisting of 8 key elements, wraps care around the patient 24×7 by fully integrating the hospital and home care team, providing the patient and caregivers with one point of contact, and enabling both hospital and homecare staff to access the same patient record.
These 8 key elements of the ICC model all contribute to improved health outcomes for patients. In particular the combination of robust education provided to the patient and their caregiver(s) while in hospital and again by home care resources while in the home, along with the 24×7 access to care are powerful enablers.
In 2015, St. Joseph’s Healthcare Hamilton (SJHH) was selected by the ministry as the lead of 1 of the 6 ministry funded bundled care pilot programs. This pilot program was referred to as the HNHB Integrated Comprehensive Care (ICC) 2.0 (COPD/CHF) Program. Since that time, Niagara Health has worked with SJHH to spread and scale this program to all three NH acute care hospital sites and supported spread and scale to all other acute care hospitals in HNHB LHIN.

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