March 2016

My last two posts focused on the Patient's First: A Proposal to Strengthen Patient-Centred Health Care in Ontario discussion paper and with all the media attention and public engagement surrounding it's release, it is easy to get caught up imagining what the future of our health system might look like.

As our 2015-16 fiscal year comes to a close however, rather than looking forward, I want to look back on what has been one of the great success stories to come out of our LHIN this past year - the expansion of the Integrated Comprehensive Care (ICC) Program.

The ICC Program is an innovative model of care that directly integrates hospital and community care services for patients. Initially launched as a pilot at St. Joseph's Healthcare Hamilton in 2012, the program was a direct response to the concerns of patients who found accessing care after leaving hospital to be challenging and confusing.

From the perspective of the LHIN, for a program to be successful it must deliver against at least one of the three elements of our strategic aim, which is to dramatically improve the patient experience through quality, integration and value. In the case of the ICC Program, we have observed a significant improvement in all three measures.

Under the program, patients from certain groups, including those undergoing hip or knee replacement, thoracic surgery and those living with Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure (CHF) are provided with an Integrated Care Coordinator who acts as their "quarterback" ensuring seamless access to the right care at the right time.

By eliminating unnecessary barriers to receiving the care they need when they need it, the ICC Program is achieving truly impressive results for patients. Those enrolled in the program are spending less time in hospital and more time at home, experiencing fewer emergency department visits and fewer readmissions to hospital. Above all, patients are very satisfied with the care they have received, feel they are very well supported in their health care journey and are much less anxious about being discharged home from the hospital.

Key to the program is a bundled-care model where a single "parcel" of funding per patient is provided to support the integrated provision of care. This model allows the Integrated Care Coordinator to wrap care around each patient by understanding their individual needs and proactively accessing the specific health services required to meet those needs. Patients enrolled in the program are supported by a network of health care providers in the hospital and in the community and are able to access a member of their care team by phone at any time of day or night with questions or concerns.

A perfect example of the difference the ICC Program is making for patients is the story of Ilene Mulholland. The 79-year-old Hamilton resident was first enrolled in the program three years ago after being hospitalized for COPD. At the time she was having a difficult time managing her condition and her health was deteriorating. Ilene is doing much better now and credits early intervention measures with twice keeping her out of hospital, when her home care team detected a lung infection and activated her “action plan,” changing medications based on standing orders. She also feels more confident and safe knowing she can call to have a team member come check in on her if she has a flare up, something she has done on multiple occasions.

The success of the ICC program within the St. Joe’s system has garnered a lot of attention, including from the Ministry who last year issued a province-wide Expression of Interest calling on providers to submit their own innovative, patient-centred proposals. Working together with our partners in hospital, primary care and home care, we submitted a successful application that will see the Program expand to all acute care hospital sites across the LHIN beginning with patients suffering from COPD and CHF.

In addition to St. Joe's, Joseph Brant Hospital, Hamilton Health Sciences and Brantford General Hospital have already started using the ICC model and over the course of the next year it will roll out into all the remaining hospitals in our region. This expansion will ensure that no matter where they live in our LHIN, patients will have equitable and timely access to care based on leading practices and that care pathways will be standardized to ensure common standards across hospital sites. It also means health care dollars and resources will be used more efficiently by integrating resources across the continuum of care.

I for one am extremely proud to see innovations like the ICC program originating within our LHIN and will be closely tracking the outcomes as more hospital sites begin using this model of care.

Update on Patient's First Proposal Engagement

While I did mention above that I wasn't going to focus on the Minister's discussion paper again this month, I will give a quick update for those who have been following what we've been up to.

As a LHIN we concluded our consultation activities at the end of February and submitted all feedback we received to the Ministry on February 29. Over the course of our consultations we met with, spoke to and heard from 1,270 health system users and stakeholders. An overview of our activities and what we heard was shared at our last board meeting.

This presentation to the board, along with all the feedback we sent to the Ministry can be viewed on our website at the following link

If you or your organization would like to be featured in a future blog or share a patient story in one of our Voices in the Community videos you can reach us through our office, or if you’re on social media via our Twitter handle - @HNHB_LHINgage. Your feedback and questions are always welcome.