Ontario hospitals will soon roll out a new model of patient care that was tested out in Hamilton.

Health Minister Dr. Eric Hoskins, speaking at a recent Empire Club of Canada event, said the province is urging hospitals to move toward a “bundled” approach to health care that aims to guide patients throughout their entire medical treatment.

And Hoskins cited St. Joseph’s Healthcare Hamilton’s Integrated Comprehensive Care Project, which started in the spring of 2012, as a leader when it comes to this treatment approach.

The St. Joe’s ICC program is in place for patients who require hip or knee replacement surgery, lung cancer surgery and treatment or those who have chronic heart or lung conditions.

'It is the best way to care for our patients.' - Donna Johnson, St. Joseph's ICC Project Lead

In 2013, a report shows 1,065 patients experienced the new approach, which pairs patients with a care coordinator — most often a registered nurse — from pre-operation treatments to post-surgical home care.

"This is an entire team that cares for them during that entire trajectory," said ICC Project Lead Donna Johnson.

Johnson said there have been a number of benefits associated with the project including improved patient outcomes, the ability for patients to receive more treatment at home instead of in hospital — a desirable outcome for patients and hospital administrators alike — and "significant" cost savings that can be as much as $4,000 per person each year in some cases.

The program also addresses issues that come up once patients are recovering at home.

"Often patients would feel that there are gaps when they go from being in hospital to being at home," Johnson said.

Now, care coordinators schedule home visits equipped with mobile phones and iPads so if they can’t help patients they can easily connect with doctors via technology like Skype.

"Often the phone call is all that’s required," Johnson said, noting the program also has a 24/7 phone line patients can use if they’re having troubles.

Opportunities to expand

Johnson said the hospital is exploring opportunities to expand the ICC project. Mental health patients, she said, may be a group that could benefit from being paired with a social worker serving as a care coordinator.

The hospital has also begun testing the program at St. Mary’s, a community hospital in Kitchener, Ont. where it’s also working well and may be expanded.

"I think regardless of where you are in the province it would really benefit," Johnson said.

Patients, Johnson said, have relayed glowing praise for the program. One man, who had one hip replaced pre-ICC and the other during the pilot said he thought if ICC existed during his first surgery he likely wouldn’t have needed the second surgery.

In his speech, Hoskins said the program had cut down on the number of hospital re-admissions and referrals to rehabilitation programs.

Johnson, who is also a nurse manager, said inside the hospital she hasn’t heard anybody complain about the program.

"It is the best way to care for our patients," she said.