Debra Wong, Integrated Care Coordinator, plays a vital role in helping patients with chronic conditions confidently transition from hospital to home.
When Katherine Safer first heard about Niagara Health’s Integrated Comprehensive Care (ICC) program, she didn’t realize it would change her life.
Living with chronic obstructive pulmonary disease (COPD), Safer has been enrolled in the program multiple times over the past five years, giving her the tools and support she needs to manage her condition at home.
“The program is another level of care,” says Safer. “Personal support workers help with daily tasks, nurses provide personalized support with my medications and the coordinator is always checking in to make sure I have what I need.”
The ICC program is a 60-day initiative designed to help patients with chronic conditions like COPD and congestive heart failure transition from hospital to home care. Patients receive coordinated services, including home nursing visits, physical therapy and access to a 24/7 helpline.
One of the biggest benefits for Safer is the consistency of care.
“Seeing the same healthcare providers over time makes a huge difference,” she says. “Being able to build relationships with my care team in the comfort of my own home has made managing my condition much more doable.”
Unlike traditional post-discharge care, the ICC program offers a more holistic approach. Patients not only receive medical guidance, but also support with finances, transportation and mental health through social workers and community organizations.
“Managing a chronic disease can be overwhelming,” says Debra Wong, Integrated Care Coordinator. “Patients are dealing with new medications, lifestyle changes and stress. When they leave the hospital, they’re often scared. We make sure they’re not left alone to figure everything out.”
Once a patient is identified as eligible for the ICC program, a coordinator meets with them in the hospital to develop a personalized care plan. Within 24 hours of discharge, a nurse visits the patient’s home to begin the transition.
“The key to success is having an action plan,” says Wong. “We teach patients how to recognize worsening symptoms and what to do when that happens. Quick intervention can prevent Emergency Department visits and readmissions.”
The program also ensures continuity of care by using shared electronic medical records.
“With everything charted in one place, we avoid redundancy and make sure all healthcare providers involved in the patients’ care are on the same page,” says Wong.
One patient recently discovered just how vital the ICC program can be.
After being discharged with chronic heart failure, the patient wasn’t sure how to manage his condition at home. The ICC program team stepped in, providing education, regular nursing visits and continuous support.
One morning, a routine check-in call from an ICC nurse led to a critical hospital visit. The patient explained to the nurse that he was experiencing swelling and an increasing heart rate. The nurse advised him to seek medical attention immediately. Quick action led to hospitalization, where doctors were able to stabilize his condition.
“This call saved my life,” the patient later said.
The patient was readmitted to the ICC program after discharge and continued receiving vital support.
“The first visit I had with an ICC nurse provided me with information about the new medication I needed,” the patient recalls. “The nurse also gave me suggestions to reduce swelling in my legs and feet. Without this program, I don’t know how I would have managed.”
According to Ontario Health, hospitals with ICC programs have seen a 30-per-cent decrease in emergency visits among patients with chronic conditions. The model is gaining traction across the healthcare system to improve patient outcomes while reducing strain on hospitals.
For Wong, the most rewarding part of her job is seeing patients gain confidence in managing their conditions.
“When we hear things like ‘I feel like I can still have quality of life’ or ‘The ICC program saved my husband’s life,’ it reinforces why this program is so important.”
As Safer puts it, “The ICC program is top-of-the-line. I have nothing but kudos for everyone who has helped me along my healthcare journey.”
