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Program provides discharged patients enhanced access to services in community

Posted Dec 14th, 2016

Program provides discharged patients enhanced access to services in community

Discharged patients at risk of readmission now have enhanced access to services in the community and medical expertise, thanks to a new model of care designed to reduce unnecessary trips to the hospital.

The Integrated Comprehensive Care (ICC) program, launched by Niagara Health in April 2016, directly integrates hospital and community care services for patients who are admitted with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) and require home care after discharge.

Key to the program is a team of Niagara Health Integrated Care Co-ordinators who help patients through every step of their journey, in the hospital and back into the community.

Here’s how the program works:

While in hospital, patients who have been diagnosed with COPD and CHF are connected with an Integrated Care co-ordinator. 

The co-ordinator is the patient’s link between hospital specialists and connects them with necessary service providers in the community, including home care provided by St. Joseph’s Home Care. 

Patients and their family members have access to support on a 24/7 basis while enrolled in the program.

The program provides patients 60 days of support post-discharge from hospital.

The use of mobile technology, such as iPads, allows home care staff to update the care team in real time with any changes to a patient’s condition, and staff review all patients in the program on a weekly basis holding “virtual rounds.”

Barb Berketo, one of the Integrated Care Co-ordinators, says the program has been well received by patients and their families.

“It’s meeting a need that’s out there,” says Ms. Berketo, a Respiratory Therapist. “When we offer the program to the patients and families, it’s usually a sense of relief for them.”

Important to the program, she says, is educating patients about how they can manage their symptoms at home.

“People are finding it really satisfying. They want to stay home. They can call us if they have any questions, or we can send a nurse that day or a respiratory therapist to help them. If the healthcare team has any concerns, they email us (the co-ordinators) right away.”

Derek McNally, NHS Executive Vice-President of Clinical Services and Chief Nursing Executive, adds:  “This is a wonderful example of an innovative model of care that creates a seamless patient journey and ensures patients have timely access to medical expertise. Patients are well supported by a network of healthcare providers in the hospital and the community, which will help reduce their anxiety about being discharged home from the hospital.”

The program builds on the success of St. Joseph’s Health System’s early work in launching an innovative approach to integrated care and currently includes all  acute care hospitals in the Hamilton Niagara Haldimand Brant LHIN. Early results across the LHIN suggest we are doing a better job of caring for individuals with congestive heart failure and COPD.

Niagara Health hopes to expand the ICC program to other patients in our care in the future.

Goals of the program include:

  • Improved patient satisfaction
  • Fewer readmissions to hospital
  • Shortened hospital stays

Niagara Health System