Integrated Comprehensive Care Program

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 the Waterloo Wellington Local Health Integration Network. 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 will be expanding the patient groups it serves. It began by offering 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

One Person Coordinates Care

Integrated care coordinators help patients navigate every step of their healthcare journey in hospital and after they go home. The coordinator is a connection point with family doctors, nurse practitioners, specialists and community services. Coordinators work on behalf of patients to ensure timely communication and care.

24/7 Access to Care

Team members have access to patients’ electronic health records. The nursing team, which is available by phone 24 hours a day, 7 days a week, can use this record to provide informed advice and support to patients.

In addition to their care coordinator, patients in the ICC program are supported by a community care team which may include:

  • Nurses
  • Personal Support Workers
  • Physiotherapists
  • Occupational Therapists
  • Dietitians
  • Speech language pathologists
  • Respiratory therapists
  • Social workers

Proven Results

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.

Community Involvement

Membership in KW4 OHT

St. Mary’s General Hospital is a proud member of the KW4 Ontario Health Team (OHT). The KW4 OHT was approved in October 2020 by the Ministry of Health. It is comprised of health and wellness partners working with the people of Kitchener, Waterloo and the Townships of Woolwich, Wilmot and Wellesley to co-design our healthcare system to better meet the needs of our diverse community.

The goal is a health system for all 400,000 residents that offers seamless, interconnected care and continuity across providers, including hospitals, primary care, long term care and community agencies.

Referral Process

Cardiac, Lung or Esophagectomy Surgery Patients

These patients will be connected to their care coordinator either prior to surgery or one to two days after surgery.

Chronic Obstructive Pulmonary Disease (COPD) or Congestive Heart Failure Patients

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:

Kathleen Demers
Director, Chest and Integrated Comprehensive Care Program