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Workshop Abstracts

Achieving Scale – Using an Integrated Comprehensive Care Model to Transform the Patient & Provider Experience


Melissa Chang

University Health Network, CA
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St. Joseph’s Health System’s (SJHS) Integrated Comprehensive Care (ICC) is an evidence-based model of Bundled Care that supports patients with One Team, One Record, One 24/7 Number to Call, and One Fund. The focus is to ensure a seamless patient experience, while utilizing existing resources across the continuum, to deliver an integrated and comprehensive care experience.  ICC is sustainable, transformational system change enabled by an integrated service delivery and funding model.

Having successfully spread and scaled this model regionally, and more recently at the University Health Network (UHN) in Toronto, Canada’s largest urban centre, workshop participants are encouraged to join this session to understand SJHS & UHN’s perspectives on how this model can be implemented and scaled within diverse health systems. 

After this session, participants will:

•Understand the key constructs of the four pillars of ICC:  One Team, One Record, One 24/7 Number to Call, and One Fund

•Understand how to apply the ICC framework within their own organizations and/or regions


Patients seek better outcomes and experience from their health system, and providers need to find a new sustainable approach to manage financial and human resources.  Since 2012, the evidence-based ICC model has delivered impressive outcomes in all aspects of the Quadruple Aim, for over 20,000 patients, across numerous surgical and chronic/complex care pathways.

ICC is made up of four pillars - we work together as One Team including patients/caregivers, hospital, home and community and primary care. One Record ensures a complete digital health record is accessible by the care team. One 24/7 Number to Call to provide patient, families/caregivers access to the care team. These components are enabled by an integrated funding model, referred to as One Fund. Integrated funding is a key enabler for system redesign; it aligns the right incentives, empowers stakeholders and drives value across the care continuum.

The principle of patient/provider co-design and the iterative nature of program development support the creation of trust, transparency and common purpose for those involved in delivering care across the continuum of care.  ICC is adaptable over time, which ensures its ongoing effectiveness.

At SJHS, the ICC program has resulted in a savings of up to $4,000/patient, 30% reduction in emergency department visits and 30% reduction in hospital readmissions with a 98% patient satisfaction rating. Most recently, an independent peer reviewed evaluation of the ICC program for Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) patients resulting in the following finding;

•              20% reduction in acute length of stay

•              37% reduction in readmissions

•              20% relative reduction in emergency department visits

In addition, the report highlights that if the ICC program for COPD and CHF patients was spread provincially to all 18,538 patients in Ontario, an estimated cost avoidance of 13,502 hospital days and $24.1M dollars could be achieved.

Preferred Length

90 min workshop/interactive session


Overview and educational break-out sessions to facilitate application of four pillars in participants regions.

Target Audience

Any participants interested in application of Integrated Care models.


How to Cite: Chang M. Achieving Scale – Using an Integrated Comprehensive Care Model to Transform the Patient & Provider Experience. International Journal of Integrated Care. 2021;21(S1):371. DOI:
Published on 01 Sep 2021.
Peer Reviewed


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