Integrated Comprehensive Care – A Case Study in Nursing Leadership and System Transformation Laura Wheatley, MHSc Hamilton Niagara Haldimand Brant (HNHB) Integrated Comprehensive Care Lead St. Joseph’s Healthcare Hamilton Hamilton, ON

Winnie Doyle, RN, BScN, MN Executive Vice President Clinical Programs and Chief Nursing Officer St. Joseph’s Healthcare Hamilton Hamilton, ON

Cheryl Evans, RN, MScN Acting Director of Nursing St. Joseph’s Healthcare Hamilton Hamilton, ON

Carolyn Gosse, RPH, ACPR, PharmD Vice President of Integrated Care, St. Joseph’s Health System President, St. Joseph’s Home Care Hamilton, ON

Kevin Smith, DPhil CEO St. Joseph’s Health System Hamilton, ON

Abstract Calls for transformational change of our healthcare system are increasingly clear, persuasive and insistent. They resonate at all levels, with those who fund, deliver, provide and receive care, and they are rooted in a deep understanding that the system, as currently rigidly structured, most often lacks the necessary flexibility to comprehensively meet the needs of patients across the continuum of care. The St. Joseph’s Health System (SJHS) Integrated Comprehensive Care (ICC) Program, which bundles care and funding across the hospital to home continuum, has reduced fragmentation of care, and it has delivered improved outcomes for patients, provid- ers and the system. This case study explores the essential contribution of nursing leadership to this successful transformation of healthcare service delivery.



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Introduction Healthcare providers and organizations are challenged to consistently deliver high-quality care within the current system, especially for those with complex and chronic conditions. From the perspectives of patients and providers alike, episodes of care are too often fragmented and lack integration between sectors and provid- ers. If we are to improve the patient experience and health outcomes and ensure optimal value for the system, the design of care delivery must change. Patient- centred care and coordination of care are by no means new concepts; however, building healthcare services that enable these concepts to live every day for every patient has not come easily. Historically, patient movement between acute care and community home care services has often been typified by:

• Continuity of care disruptions at each transition point, leading to poor integration of care, higher risk of readmissions and unwarranted costs.

• Communication gaps and patient dissatisfaction created during the process of transfer, often described in terms of contradictory instructions, lack of clarity on self-care expectations, uncertainty about whom to contact when problems arose and strain on the patient and family with requests to repeat their story multiple times to multiple care providers.

• The absence of fiscal incentives directly tied to outcomes, complications, alternate level of care days and readmissions.

This context of perceived fragmentation, growing dissatisfaction, suboptimal health outcomes and growing costs has created a fertile ground for a visionary redesign of care delivery between acute hospital care and community care, with nurses providing crucial leadership in this transformation.

With increasing agreement for the need for widespread health system transforma- tion, the Canadian Nurses’ Association and Canadian Medical Association (2011) jointly identified principles that should underlie and guide such changes. These principles are fundamental to the Integrated Comprehensive Care (ICC) project and include commitments to patient-centered care, quality, health promotion and illness prevention, equity, sustainability and accountability (Box 1). Nurses, by virtue of possessing in-depth clinical knowledge and expertise, understanding of the social determinants of health, having a unique connection with patients and families in times of both health and illness across the lifespan, and playing an inherent coordinating role between patients and a myriad of healthcare providers, are well positioned to provide the leadership necessary to enact these principles and to enable the transformation that is needed (CNA 2013). Within this project, such nursing leadership emerged and was supported. Nurses in formal leader- ship roles leveraged the skills and abilities of all interprofessional team members and encouraged and empowered them to test traditional boundaries, innovate



35Integrated Comprehensive Care – A Case Study in Nursing Leadership and System Transformation

and imagine how patients could and should be engaged as active participants in care planning and delivery. Nurses in informal leadership roles embraced a more autonomous role, working to their full scope of practice, in collaborative partnership with other healthcare providers, patients and families.

The work to redesign the pathway between hospital and home care began with clinicians and patients re-imagining and co-designing processes that would ensure better integration and coordination of care to improve outcomes and reduce return emergency department visits and preventable readmissions. The emerg- ing model was called ICC and was built on the principles of “Bundled Care and Payments.” Bundled payments are a remuneration method by which two or more providers receive a pre-determined funding amount to deliver a specific episode of care; bundled care includes all the services for a specific episode of care across the continuum (pre-acute, acute and post-acute) for a defined time period (Jacobs et al. 2015; American Medical Association 2016). As the team completed the value stream mapping and built the model, seven core elements were identified and tested in the pilot. It is noteworthy that the overarching mindset and culture fostered were “make it work for the patient,” in addition to a low rules environ- ment to encourage and facilitate innovation.

Intervention St. Joseph’s Health System ICC Program The St. Joseph’s Health System (SJHS) (St. Joseph’s Health System 2016) includes a multisite acute teaching hospital (St. Joseph’s Healthcare Hamilton [SJHH]), a community hospital (St. Mary’s General Hospital [SMGH]) and a home care provider (St. Joseph’s Home Care [SJHC]), which positioned it well to demon- strate and evaluate bundled care and payment.

To test the model, four clinical streams of patients were selected: thoracic surgery, joint replacements (hip and knee), chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). A new bridge was built

Box 1. Principles to guide healthcare transformation in Canada 1. Enhance the healthcare experience

• patient-centred; and • quality.

2. Improve population health • health promotion and illness prevention; and • equitable.

3. Improve value for money • sustainable; and • accountable



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between the hospital and home care teams, with the new role of an Integrated Care Coordinator being that of acting as the connective tissue and bridge for each clinical stream. Three streams were led by Registered Nurses and one by a Physiotherapist.

Within each stream, the hospital- and community-based healthcare workers most intimately involved in providing care are brought together with patients they serve to redesign the process of care, which is delivered by two sectors and frequently characterized by a lack of coordination. ICC then combines the clinical teams, the clinical care and the client record into a single program to best serve the client’s needs. ICC also shifts specific clinical activities to the most effective setting, typi- cally shifting care from hospital to home, and further adds value by providing patients and families with 24/7 1-800 telephone support. The ICC model contrasts with the standard model, in which patients’ care is delivered by multiple organiza- tions and providers (including hospital, community care access centres and home care and community providers), with multiple transitions (Figure 1).

The model was envisioned as one in which rapid cycles of change and improve- ment were expected, and the model would evolve in response to emerging evidence and data. Consequently, planning and implementation overlapped, and

Figure 1. Comparison of standard model of care and ICC model of care

CCAC = community care access centre; ED = emergency department; ICC = Integrated Comprehensive Care; QBP= quality-based procedures.

ICC model

Home care provider

CCACHospital Community provider

Single collaborative clinical team

Single integrated care path (hospital to home)

Single medical record

Single point of contact




(± QBP, order sets, discharge

bundle, care path)




Individual providers



Primary care provider


Outpatient clinic

Community health centres

Unplanned ED visit or


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