Ana Marie MacPherson, MASc RRT CRE CTE

I currently work as the Chronic Stream, Integrated Comprehensive Care Program (ICCP) Care Coordinator at St Joseph’s Healthcare Hamilton (SJHH).  The ICCP was designed to integrate care across the hospital and home care continuum creating “One System”.  This is achieved with a single team, a single point of contact and a care management model that provides homecare support for patients admitted to SJHH in collaboration with a lead home care provider, St. Joseph’s Home Care (SJHC). High performing health and social care systems provide exceptional care and quality experiences for patients, caregivers and providers to improve outcomes while effectively utilizing healthcare dollars. In 2017, a research article by Guertin et al., stated the creation of ICCP was designed with seven elements in mind: (1) client-centered care to empower clients with knowledge, participation, and self-care; (2) integrated care coordinators who follow clients across the continuum of care; (3) integrated inter-professional care teams standardizing care pathways used in both hospital and community; (4) use of shared electronic health record which would also serve as a hub for communication; (5) use of simple and available technology to provide flexibility in communication; (6) community-based 24 hours a day, seven days a week access to healthcare; and (7) flexibility in the delivery of care in hopes of continually improving the processes of care. This care model contrasts with previous standards where patient care was not coordinated and involved multiple organizations, providers and services working in silos without a consistent and common care plan. Patients followed within the ICC program have access to the ICCP team 24 hours a day, seven days a week through a toll-free telephone number. In addition to the ICC personnel, the ICC program leverages an independent version of the SJHC Information System (Procura ContinuLink [Victoria, British Columbia]) to provide real-time remote access to client files. Remote access to these files is accomplished by using tablets, laptops, or desktop computers to securely access the information and clinical documentation remotely and provide the option to take digital pictures when required (e.g. wounds). The ICC program is currently organized into two main streams:

  • Surgical: thoracic surgery, esophagectomy, urology, total joint replacement; and
  • Chronic disease: congestive heart failure [CHF], and chronic obstructive pulmonary disease [COPD]). [1]

The pandemic has caused unprecedented pressures on the healthcare system. In response to the COVID-19 pandemic, St. Joseph’s Healthcare Hamilton has embraced and leveraged the ICCP capacity. ICCP is a model of care that is able to assist in the potential reduction of ED visits, hospital admissions and length of stays.

As the Chronic Stream ICC Care Coordinator, my responsibilities include: 

Discharge Planner/Care Coordinator: Hospital to Home

As a member of the hospital care team, my role is to facilitate a seamless transition from hospital to home in a timely manner. I screen and assess patients diagnosed with CHF/COPD within 24-48 hours of being admitted to the hospital for ICCP eligibility. Once eligible and consented for ICCP, discharge planning begins with a review of all specialist consults/recommendations and discussing the patient with the inter-professional care team during patient rounds. A care plan is developed with the patient/family to identify the support required to safely bring and keep patients home. Once a care plan has been completed and reviewed with the patient and family, then coordination of all providers/services in the community for home care support are initiated upon discharge. This care plan is modifiable to meet the patient’s needs. As the ICCP Care Coordinator, we are automatically identified as the “Single Point of Contact” to eliminate any confusion between the patient, caregivers and care team members and ensure a smooth transition from hospital to home and/or community.

Care Coordinator: Home and Community

Unique to the ICC Program, the Care Coordinator role and responsibilities extend outside of the hospital walls, to home and community. As a single point of contact for the ICCP and to streamline processes, the care coordinator is responsible to follow each patient for 60 days post hospital discharge, ensuring supports are in place to avoid readmission.

I receive all rostered patient calls during business hours, as part of our Home Care Team responding on a 24/7 basis. The home care team escalates any issues or concerns directly to me immediately to follow up. Together with the home care team, I facilitate medical connection/contact and action when the patient is concerned about symptoms when home; to provide direct care as appropriate to mitigate any immediate need (eg. Implementing an action plan such as Lasix titration, or starting antibiotics or prednisone) and to coordinate follow up appointments as needed with the patient’s Family Physician, specialist, or other relevant clinics.

The “One Team”, provides individualized support as coordinated by the ICCP Care Coordinator, using a small dedicated team trained for managing COPD and/or CHF. This One Team is an Interprofessional Team composed of: St. Joseph’s Home Care (Nursing/PSW), St. Elizabeth Health Care (OT/PT/RD/SW/SLP), ProResp (RRT), the COPD/CHF Care Team (NP/RN/ Respirologists/Cardiologists), and community Paramedics, complimenting care management provided by the patient’s General Practitioner.

In addition, I follow-up, monitor and educate patients in order to address their health needs – physical, mental, or social. Along with coordination, I assist in system navigation to support any other patient needs. In monitoring the patient health status, documentation is maintained in the community portal (Procura) for others to view, and any concern is communicated to the most appropriate provider (GP, specialist, clinic).

Prior to care completion with the ICC Program, a smooth Transfer of Accountability is initiated with ample time to the most appropriate provider, or more commonly, transitioned to community services. This is done to avoid any gaps in care, thus avoiding readmission.

COVID 19 Pandemic Strategies for the ICCP Chronic Stream

In preparation for Pandemic: 

Patients were discussed and prioritized according to their current and potential needs. These were provided accordingly:

  • Action Plan
  • Prescription
  • Follow-up appointments to be made with GP/Specialist/Clinics

During Pandemic:  

Remote Patient Monitoring capacity was increased for patients diagnosed with COPD and/or CHF

  • In collaboration with the community Paramedics’ Remote Patient Monitoring Program

Follow up via virtual visits with clinics used as alternate for in-person visits:

  • Phone calls easily accessible
  • Video conferencing for those with capacity/access
  • Increased visits for those who lived alone, to avoid feelings of isolation, anxiety, depression
  • Follow up q 2-3weeks for those with smoking challenges, to keep them on track

Healthcare needs for any other reason:  ICCP Patients are provided with one number to call 24/7 for any concerns or questions to speak to a health care provider. Providers have access to the patient’s record remotely via Procura to enable the right care at the right time.

St. Joseph’s HealthCare Hamilton, St. Joseph’s HomeCare, St. Elizabeth and ProResp are organizations that have embraced collaborative models of response and care and were already working to advance integration pre-pandemic, which has appeared to be more effective in responding as one connected team and community.

The Respiratory Therapy foundational training includes caring for people of all ages from neonates to geriatrics, in acute, emergency, diagnostic, research, rehabilitation, chronic management, primary, and community care. Similar to other professions, added certification, skills and education allows us to move to an advanced level of care that we can provide our patients. I have been very fortunate that my profession, education and experience in diverse settings have allowed me to be able to support the needs of vulnerable populations in the community. I am forever grateful to the ICCP Team Lead for giving me this amazing opportunity. I am proud to be an RRT.

Whether you are a new graduate RT or have worked in the field for many years, continue your lifelong journey of learning and professional development. Think about where you want to be 20 years from now. I am where I want to be!

Best Choice.

Right Care, Right Time, Right Profession.

[1] Canadian Respiratory Journal, Volume 2017, Article ID 7049483, 10 pages,
Preliminary Results of the Adoption and Application of the Integrated Comprehensive Care Bundle Care Program When Treating Patients with Chronic Obstructive Pulmonary Disease

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