ICC Program a breath of fresh air for Betty Tree

Betty Tree knows first-hand how Chronic Obstructive Pulmonary Disease (COPD) can make the simple act of breathing a terrifying struggle. For 20 years she’s had countless visits to her family doctor to cope with her COPD, which literally took her breath away.

In Dec. 2017 Betty suffered a heart attack, which complicated her existing condition, but now she has a brand new lease on life thanks to the help of St. Joseph’s Health Systems Integrated Comprehensive Care (ICC) Program for COPD and Congestive Heart Failure (CHF) patients. The program was launched at The Brantford General in 2015.

“Anybody that’s admitted here with COPD or a CHF diagnosis, qualifies for this program,” Brant Community Healthcare System (BCHS) Registered Nurse and ICC Program co-ordinator Andy Cleverdon explained.

“The ICC program is a customized care approach that was developed by St. Joseph’s Health System back in 2012 for COPD and CHF patients. Since then it has been adopted by most acute care hospitals in the Local Health Integration Network.”

Through the ICC Program patients participate in creating personalized care plans and receive home care, which can alleviate the need for frequent Emergency Department visits or hospital admissions.

The ICC approach includes a 24-7 hotline access to a clinician for questions or concerns, a single dedicated point of contact and access to members of the St. Joseph’s Home Care Team comprised of nurses, respiratory therapists, physiotherapists and occupational therapists, social or personal support workers. Andy Cleverdon coordinates and oversees the care received by patients for 60 days following discharge from hospital. If there is any significant change in the patient’s condition, Andy ensures primary care physicians are informed and care plans are adjusted based on recommendations from the ICC team.

To date, over 2,000 patients have been screened for the two-month program, with 450 people enrolled. Admitted patient stays have been reduced by almost three days, Andy said. Considering that COPD and CHF patients have high readmission rates, the days saved means opening up to 1,000 inpatient bed days that otherwise would not have been available.

“We also saw reductions in overall ED visits by 31 percent and 18 percent in readmissions hospital wide. It is working beyond our expectations,” he said.

Action plans customized for each patient provides access to antibiotics and steroids from their pharmacists before a respiratory attack preventing further complications.

“It’s a wonderful program,” Betty said. “Andy made up a book that we keep so if we have a problem we can look through it and it will tell you what to do. We also had nurses coming in, teaching us different things on what to do if something happens.

“In the book is a whole section on exercises to do and what not to do. I learned a lot and am really glad I was in the program.”

The program also focuses on caregivers who often will notice complications before the patient does.

Betty’s daughter and caregiver, Viki Tree, said the program has helped her better identify the symptoms between Betty’s COPD and CHF.

“It helped us to tell the difference between the two and what we should do for each one,” Viki said. “It’s very difficult to tell the difference between COPD and CHF because in both cases you can get very similar symptoms.

“With the nurses there you can always call them and tell them what is happening and they can give you an idea of what you can do, or what you can put in place to help with the symptoms; or whether you should go to the doctor… this gives you a plan of action.”

Andy also works closely with the Community Paramedic Program and refers patients that are still at-risk at the end of the 60-day ICC program.

“The Community Paramedics go in and assess a patient,” Andy said. “They’ll check their vital signs, and listen to their chests.”

Information is logged into a home monitoring system so at-risk patients can be monitored daily by the CPP team. If something is amiss, a paramedic will alert the patient to adjust their oxygen, or provide additional support.

Sara Evans, an RN and home care worker with St. Joseph’s, said the number of patients the ICC Program has helped thrills her.

“We’ve had a lot of good results with it,” Sara said. “I think we’ve helped a lot of people understand that (COPD and CHF) isn’t necessarily something that needs to hold them back. I think people better understand what they can do if they feel like they are getting sick with the teaching we provide.

“We’ve decreased hospital ED visits and readmissions, and that makes you feel pretty good too.”

Betty and Viki are champions of the ICC Program, saying it has greatly helped improve their quality of life.

“As far as peace-of-mind goes, you are in a much better position after having done the program, by far,” Viki said.

As the Tree family knows first-hand, when a health crisis or emergency affects you or a loved one, Brant Community Healthcare System is here to provide exceptional, professional and compassionate care in your time of need.

Behind the success of services like the ICC Program is the support of the BCHS Foundation and the generosity of our community, our donors and volunteers. This continued commitment has enabled the BCHS Foundation to put patients first by helping us to provide the right equipment or support the right service, at the right time, when it matters most.

The ICC Program is one of many valuable community programs administered by the Brant Community Healthcare System and supported by donations to the Brant Community Healthcare System (BCHS) Foundation.

Now is the time to make a difference, please consider making a gift today that is meaningful to you, and support a strong healthcare system for our community.

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