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Integrated Comprehensive Care

The Integrated Comprehensive Care (ICC) Program is a patient-centred model of care that links hospital and community care services. It was first launched by St. Joseph’s Healthcare, Hamilton in 2012, followed by St. Mary’s in 2013. The program transitioned from St. Joseph’s Home Care in November 2017 to partner with Home and Community Care Support Services Waterloo Wellington. The ICC program offers:

  • Smoother transitions from hospital to home
  • Education to help patients manage their care
  • Better communication between care providers

At St. Mary’s, the ICC program offers care to patients who have:

  • Undergone cardiac, lung and esophagectomy surgeries
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure (CHF)

How the ICC Program Helps Patients

Integrated care coordinators help patients navigate every step of their healthcare journey in hospital and after they go home. Coordinators work on behalf of patients to ensure timely communication and care.

ICC Team members have access to patients' electronic health records and work closely with St. Mary's Hospital Team. With recommendations from the Hospital Team, ICC Coordinators can involve community care team members which may include:

  • Nurses
  • Personal Support Workers
  • Physiotherapists
  • Occupational Therapists
  • Dietitians
  • Speech-Language Pathologists
  • Respiratory therapists
  • Social Workers

ICC provides the right care in the right place. The program allows patients to receive quality, cost-effective care in a well-organized way. Patients spend less time in hospital and are less likely to return to the Emergency Department or be readmitted. Patients are less anxious about going home from hospital and feel well supported by the team once they return home.

Referral Process

These patients will be connected to their care coordinator either prior to surgery or during discharge planning.

Patients with COPD or CHF will be referred to the ICC program by the healthcare team while in hospital. The care coordinator works with the patient and family, as well as the healthcare team, to coordinate the plan of care from hospital to community.

If you have questions about the ICC program please contact:

Brad Jones

Interim Integrated Discharge Planning Manager
Home and Community Care Support Services Waterloo Wellington & St. Mary's
519-749-6578 ext. 5587