Integrated Comprehensive Care at St. Joseph's Health System Improves Coordination and Reduces Costs

Rationale / Objectives

Population aging combined with increasing levels of chronic disease and comorbidity puts pressure on health systems to deliver care more efficiently. Gaps in coordination and breakdowns in transitions of care between settings are problematic for many patients and families, particularly in the transition from hospital to home care. St. Joseph’s Health System (SJHS) includes both an acute teaching hospital and a home care provider in the same city. Enabled by funding from the Ministry of Health and Long-Term Care and a collaborative effort within the Hamilton Niagara Haldimand Brant Local Health Integration Network (LHIN), the organization developed the Integrated Comprehensive Care Project (ICCP) to deliver integrated care for select patient groups since March 2012.

Project/Program Description & Major Achievements

St. Joseph's Health System engaged key stakeholders and conducted a value stream mapping exercise to identify issues in care integration for patients. (See the following article for more information on: What is Value Stream Mapping?) This exercise identified a number of barriers including fragmentation between Hospitals, CCAC and Home Care Providers resulting in home care being delivered in silos with little collaboration between physicians, and independent home care providers. Continuity of care was therefore disrupted for clients resulting in complications, ED visits, readmissions, and costs. In addition, duplication of information provided further frustration. Key elements of the ICCP model developed included the use of Case Navigators to follow patients from their hospital admission, through discharge to their home, and finally to independent living; and a bundled model of funding based upon predetermined payments for specific patient populations. Achievements of the ICCP program pilot included a reduction in hospital length of stay for total joint replacement and thoracic surgery; direct case cost savings; improved care coordination and increased patient satisfaction. For example, among lung cancer surgical patients, a decreased length of stay (LOS) was observed resulting in significant savings ($1,500+ per patient/client), decreased ER visits (9% versus 13%) and an overall reduction in hospital costs representing a 15%‐23% savings per patient. In addition, a 50% reduction in the time it takes to complete a home visit was achieved through improved processes.   

Lessons Learned

Critical success factors included: the Integrated Care Coordinators/Case Navigators; partnership with a service provider in the community; shared electronic health record; timely access to medical care; flexibility in communication (skype, phone calls, emails etc.); having a central contact number with patient access to the team (24/7). Opportunities for expansion include replication across different care teams and different patient populations.

People / Organizations Involved

Further Description

Originally conceived as a one year pilot program to demonstrate an innovative model of care that directly integrates hospital and community care services for patients, the program has been expanded to include three streams (lung cancer surgery, hip and knee replacement surgery and chronic disease) in collaboration with all partners in the Hamilton Niagara Haldimand Brant region. In this model, the patient moves to a different environment, their home, but the team remains the same. The Integrated Care Coordinator is a key person in this model of care; they help 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. The patient or family members can access the team on a 24/7 basis at any time during their care, by calling a central contact number. Simple, inexpensive technology is used to deliver care, using tablet computers to maintain an electronic health record and communicate with the health care team and the patients/families in the home. 

Major Achievements

The Programs for Assessment of Technology in Heath (PATH) Research Institute conducted an evaluation of the pilot project and selected highlights from various sources are included in the table below. For more detailed information on results from both medical and surgical patients, including readmissions and ER visits, please see the following presentation: Integrated Comprehensive CareThe ICCP program has recently been expanded to all acute care hospitals within the Hamilton Niagara Haldimand Brant Local Health Integration Network (LHIN) for patients admitted to hospital with chronic obstructive pulmonary disease and congestive heart failure and who require home care following discharge. Accreditation Canada awarded the program with status as a leading practice for its work.

Thoracic Surgical Cases  Control Group (FY 2011/12) ICC Group (FY 2012/13)
CMG LOS Cost* LOS Cost
112 (partial/open) 6.18 $10,043 6.14 $10,125
112 (total/open) 8.01 $12,825 6.28 $9,318
112 (radical/open) 16.5 N/A 7.25 N/A
114 (partial/endoscopic) 4.37 $6,749 3.63 $5,623
114 (total/endoscopic) 7.02 $11,821 4.72 $7,919

*non-operating room costs for thoracic lung resection for typical surgical cases