St. Joseph’s Health System (SJHS) SJHS is one of the largest corporations in Canada devoted to health care. Our member organizations provide excellent, compassionate care across the continuum. St. Joseph’s Home Care St. Joseph’s Lifecare Centre, Brantford St. Joseph’s Villa - Dundas St. Joseph’s Health Centre Guelph St. Mary’s General Hospital, Kitchener SMGH provides adult, acute care to people in Waterloo Region and beyond. As home to the Regional Cardiac Care Centre SMGH provides a full range of cardiac care including surgery, angioplasty, and pacemaker insertions. SMGH continues to meet the needs of the community, recently opening a 100,000 sq. ft. addition. No. of beds: 160 No. of Staff: 921 Annual budget: $120 M Established: 1924 www.smgh.ca St. Joseph’s Healthcare, Hamilton SJHC provides a multitude of services that respond to community needs. Mandate is to help people including the frail, elderly, and disabled, lead more independent lives. This is done through nursing, personal and home support, and volunteer services, as well as our Constant Care, Palliative Care, Healing Touch, With Seniors in Mind, and Corporate Health Programs. No. of beds: n/a No. of Staff: 164 Annual budget: $10 M Established: 1921 www.stjosephshomecare.ca SJLC is a multigenerational place of care, hope and education. The new concept of health care combines long term care with Brant County’s first hospice as well as a centre for research and academics. The SJLC commitment to the Mission and philosophy of providing compassionate care will never change. No. of beds: 205 No. of Staff: 165 Annual budget: $11 M Established: 1955 www.sjlc.ca SJV has built a new vision of long term care; one that understands that “there’s no place like home”. SJV staff embrace the mission; providing compassionate care with dignity and respect. Over $70 million in new buildings transformed the Villa and Estates into a modern home able to meet the needs of seniors and their families. No. of beds: 452 No. of Staff: 306 Annual budget: $22 M Established: 1879 www.sjv.on.ca St. Joseph’s Health Centre, Guelph has been serving the Guelph and Wellington community since it first opened as a refuge for the sick, injured, frail and the indigent in 1861. Today it is Guelph's leading, fully accredited, non-for-profit provider of resident long term care, complex continuing care, and rehabilitation services. No. of beds: 235 No. of Staff: 340 Annual budget: $30 M Established: 1861 www.sjhh.guelph.on.ca Charlton Campus is a tertiary care teaching centre, which includes the regional kidney transplant centre, oncologic surgery and a large acute care hospital. King Street Campus provides state-of-the-art, stand-alone facility including a Surgery and Satellite Dialysis Centre. West 5th Campus provides specialized tertiary mental health services for residents of Central South Region in Ontario. No. of beds: 760 No. of Staff: 4,432 Annual budget: $500 M Established: 1890 www.stjoes.ca Overall governance where we've tested the model While part of the same health system, relationships across these providers did not necessarily exist. The project enabled frontline staff to work together Past partnering with other homecare agencies International Outreach Program International Outreach has been bringing good intentions to life around the world since 1986. From Haiti to Uganda to Sudan, IOP partners with developing countries to provide training in current medical and nursing techniques, transport basic medical supplies, and make donated equipment operational. International Outreach is funded by the Sisters of St. Joseph of Hamilton, Canada and supported by member organizations and friends of St. Joseph's Health System. Projects are aimed at building capacity for sustainable programs; teams include physicians, nurses, biomedical engineers, and other healthcare personnel. SJHS Totals beds = 1,800 budget = $683M

St. Joseph’s Home Care Organizational Overview Community Support Services: Community & Marketed Services 193 employees (front-line) At Home Personal Care & Companionship Caregiver Relief and Respite Care Home Cleaning & Maintenance Food Services Supportive Housing at Gwen Lee, First Place, Park St., Wellington Terrace, Neighbourhood Model for Seniors at Risk Collaborative Care Model Retirement Home and Transitional Beds at First Place Private Personal Support Services Safety at Home Falls Prevention Community Connector Home Care Services: Visiting Nursing & Integrated Comprehensive Care (ICC) 96 employees Visiting Nursing Shift Nursing Private Duty Nursing Foot Care Integrated Comprehensive Care Program Corporate Services: 15 employees Finance and Accounting Human Resources, Payroll and Health & Safety Quality I.T. and Operations Communications Site Leadership

Imagine that the same clinician meets you before your hospital procedure, cares for you while you’re in the hospital and manages your recovery at home. Imagine having access to that person 24 hours a day, 7 days a week to give you real answers, concrete advice and expert care when you need it. Imagine that everyone communicating with you is on the same page when it comes to your health. The vision

Integrated Comprehensive Care Program: Goals Establish a seamless patient experience from hospital to home Improve provider satisfaction Improve quality and health system outcomes Reduce number of days in hospital Reduce unplanned ER visits and readmissions Improve productivity of hospital and homecare and reduce overall cost Improve efficiency of the healthcare system by integrating resources across the continuum Improve patient experience and inform provincial policy by implementing ICC LHIN wide. To fully engage key stakeholders (e.g. physicians) and patient/family in the HNHB LHIN ICC Program Before we get into the specifics of how the ICC program evolved within HNHB, let’s go over what the goals of the program are, what it consists of and what it means for patients. Goals – in no particular order. 1) Establish a seamless patient experience from hospital to home – it enables us to wrap care around the patient 24x7 2) Improve provider satisfaction - The model improves employee ability to deliver care and support the patient. Team is able to address challenges on demand as program supports flow of information and real time communication. Team also has more flexibility in delivering care 3) Improve quality and health system outcomes - Patients can be discharged sooner as they have the extra support as they transition back into the community. Patients are supported to resolve issues within the community thereby reducing unplanned ER visits and readmissions. Care is better coordinated thereby improving productivity of the hospital and homecare, reducing overall cost and Creating extra capacity within the system (for the same amount of money) 4) Improve efficiency of the healthcare system by integrating resources across the continuum - Emphasis on provider experience and patient satisfaction 5) Improve patient experience and inform provincial policy by implementing ICC LHIN wide. Actively working with ministry to support/inform further expansion 6) To fully engage key stakeholders (e.g. physicians) and patient/family in the HNHB LHIN ICC Program

Strategic Partnerships St. Joseph’s Healthcare Hamilton St. Mary’s General Hospital St. Joseph’s Home Care St. Elizabeth Rehab Bayshore ProResp Vita Aire Physicians Technology Partners - Specialists - Devices (iPads) - Primary Care - OTN (monitoring) - Apps for self management Seamless MD

Current and Proposed ICC Work in HNHB/WW LHIN As of October 2017 10,000 + Patients to Date ICC 1.0 (Original ICC Pilot) St. Mary’s General Hospital (SMGH) (Original ICC Pilot spread within SJHS) ICC 2.0 (Spread across HNHB LHIN) ICC 3.0 Start Date 2012 2013 October 2015 TBD Pilot or Program? Ongoing Program Pilot (sustainability planning to support transition to program underway) Not Started (Proposed Program) End Date? When ICC 3.0 is operationalized Pilot ends March 2019 For those hospitals that will continue with the program, when operationally realistic, transition to ICC 3.0 would take place N/A Participating Hospitals St. Joseph’s Healthcare Hamilton St. Mary’s General Hospital 9 Hospitals in HNHB LHIN (NSCS, NGNG, NWHS, HHSJ, HHSG, HHWH, SJHH, BCHS, JBH) SJHS (SJHH and SMGH) and Niagara Health System (NHS) to start Patient Cohort(s)? Chronic Lung Disease Heart Failure Lung Cancer Surgery Hip and Knee Replacement Esophagectomy Cardiac Surgery ALL patients receiving scheduled care Duration of care path Indefinite 60 days Will vary depending on Patient Cohort Point of Enrollment Inpatient Inpatient, Emergency Department, Primary Care Scope of Bundle Post-Acute Care Single Bundle Holder Acute and Post-Acute Bundle Design TBD These are the waves To emphasize number of clients that have come through Proportion of patients that are discharged requiring HC (about 25% flow through the ICC program)