+1443 776-2705 panelessays@gmail.com
  

  1. New practice approaches
  2. Interprofessional collaboration
  3. Health care delivery and clinical systems
  4. Ethical considerations in health care
  5. Practices of culturally sensitive care

DQ1

During your practicum, determine what clinical problem or issue the organization is facing. Discuss two implications for nursing.

DQ2

What is the main issue for your organization in addressing a solution to evidence-based nursing practice? Discuss what might be the first step in addressing and resolving this issue.

Capstone Topic Summary

Due Date

Mar 25, 2022, 11:59 PM

Points

0

In collaboration with the approved course preceptor, students will identify a specific evidence-based topic for the capstone project change proposal. Write a 150-250 word summary explaining which category your topic and intervention are under (community or leadership).

You are not required to submit this assignment to LopesWrite.

Capstone Project Topic Selection and Approval

In collaboration with the approved course preceptor, students will identify a specific evidence-based topic for the capstone project change proposal. Students should consider the clinical environment in which they are currently employed or have recently worked. The capstone project topic can be a clinical practice problem, an organizational issue, a leadership or quality improvement initiative, or an unmet educational need specific to a patient population or community. The student may also choose to work with an interprofessional collaborative team.

Students should select a topic that aligns to their area of interest as well as the clinical practice setting in which practice hours are completed.

Write a 500-750 word description of your proposed capstone project topic. Include the following:

1. The problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project that will be the focus of the change proposal.

2. The setting or context in which the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project can be observed.

3. A description (providing a high level of detail) regarding the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.

4. Effect of the problem or issue, intervention, quality initiative, educational need, or collaborative interprofessional team project.

5. Significance of the topic and its implications for nursing practice.

6. A proposed solution to the identified project topic with an explanation of how it will affect nursing practice.

You are required to cite to a minimum of eight peer-reviewed sources to complete this assignment. Sources must be published within the last 5 years, appropriate for the assignment criteria, and relevant to nursing practice. Plan your time accordingly to complete this assignment.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance. 

Capstone Project: Developing a Question

Recall the components of PICOT from your research course:

(P) Population of Focus

(I) Intervention

(C) Comparison

(O) Outcome

(T) Time

Identify each of the components in relation to your approved Capstone Project topic.

P:

I:

C:

O:

T:

Then, develop a PICOT question/statement.

Examples of PICOT questions/statements:

· In adult cardiac surgery patients experiencing post-operative pain (P) immediately following surgery (P), is morphine (I) or fentanyl (C), administered intravenously, more effective in reducing postoperative (T) pain (O)?

· For immune-compromised patients, 50 years and older (P), does the use of pneumonia vaccine (I) reduce the future risk (T) of pneumonia (O) compared with patients who have not received the vaccine (C)?

© 2015. Grand Canyon University. All Rights Reserved.

33SPECIAL FOCUS ON NURSING LEADERSHIP IN HOME AND COMMUNITY CARE

Integrated Comprehensive Care – A
Case Study in Nursing Leadership
and System Transformation
Laura Wheatley, MHSc
Hamilton Niagara Haldimand Brant (HNHB) Integrated Comprehensive Care Lead
St. Joseph’s Healthcare Hamilton
Hamilton, ON

Winnie Doyle, RN, BScN, MN
Executive Vice President Clinical Programs and Chief Nursing Officer
St. Joseph’s Healthcare Hamilton
Hamilton, ON

Cheryl Evans, RN, MScN
Acting Director of Nursing
St. Joseph’s Healthcare Hamilton
Hamilton, ON

Carolyn Gosse, RPH, ACPR, PharmD
Vice President of Integrated Care, St. Joseph’s Health System
President, St. Joseph’s Home Care
Hamilton, ON

Kevin Smith, DPhil
CEO
St. Joseph’s Health System
Hamilton, ON

Abstract
Calls for transformational change of our healthcare system are increasingly clear,
persuasive and insistent. They resonate at all levels, with those who fund, deliver,
provide and receive care, and they are rooted in a deep understanding that the
system, as currently rigidly structured, most often lacks the necessary flexibility to
comprehensively meet the needs of patients across the continuum of care. The St.
Joseph’s Health System (SJHS) Integrated Comprehensive Care (ICC) Program, which
bundles care and funding across the hospital to home continuum, has reduced
fragmentation of care, and it has delivered improved outcomes for patients, provid-
ers and the system. This case study explores the essential contribution of nursing
leadership to this successful transformation of healthcare service delivery.

34 Nursing Leadership Volume 30 Number 1 • 2017

Introduction
Healthcare providers and organizations are challenged to consistently deliver
high-quality care within the current system, especially for those with complex and
chronic conditions. From the perspectives of patients and providers alike, episodes
of care are too often fragmented and lack integration between sectors and provid-
ers. If we are to improve the patient experience and health outcomes and ensure
optimal value for the system, the design of care delivery must change. Patient-
centred care and coordination of care are by no means new concepts; however,
building healthcare services that enable these concepts to live every day for every
patient has not come easily. Historically, patient movement between acute care
and community home care services has often been typified by:

• Continuity of care disruptions at each transition point, leading to poor
integration of care, higher risk of readmissions and unwarranted costs.

• Communication gaps and patient dissatisfaction created during the process of
transfer, often described in terms of contradictory instructions, lack of clarity
on self-care expectations, uncertainty about whom to contact when problems
arose and strain on the patient and family with requests to repeat their story
multiple times to multiple care providers.

• The absence of fiscal incentives directly tied to outcomes, complications,
alternate level of care days and readmissions.

This context of perceived fragmentation, growing dissatisfaction, suboptimal
health outcomes and growing costs has created a fertile ground for a visionary
redesign of care delivery between acute hospital care and community care, with
nurses providing crucial leadership in this transformation.

With increasing agreement for the need for widespread health system transforma-
tion, the Canadian Nurses’ Association and Canadian Medical Association (2011)
jointly identified principles that should underlie and guide such changes. These
principles are fundamental to the Integrated Comprehensive Care (ICC) project
and include commitments to patient-centered care, quality, health promotion
and illness prevention, equity, sustainability and accountability (Box 1). Nurses,
by virtue of possessing in-depth clinical knowledge and expertise, understanding
of the social determinants of health, having a unique connection with patients
and families in times of both health and illness across the lifespan, and playing an
inherent coordinating role between patients and a myriad of healthcare providers,
are well positioned to provide the leadership necessary to enact these principles
and to enable the transformation that is needed (CNA 2013). Within this project,
such nursing leadership emerged and was supported. Nurses in formal leader-
ship roles leveraged the skills and abilities of all interprofessional team members
and encouraged and empowered them to test traditional boundaries, innovate

35Integrated Comprehensive Care – A Case Study in Nursing Leadership and System Transformation

and imagine how patients could and should be engaged as active participants
in care planning and delivery. Nurses in informal leadership roles embraced a
more autonomous role, working to their full scope of practice, in collaborative
partnership with other healthcare providers, patients and families.

The work to redesign the pathway between hospital and home care began with
clinicians and patients re-imagining and co-designing processes that would ensure
better integration and coordination of care to improve outcomes and reduce
return emergency department visits and preventable readmissions. The emerg-
ing model was called ICC and was built on the principles of “Bundled Care and
Payments.” Bundled payments are a remuneration method by which two or more
providers receive a pre-determined funding amount to deliver a specific episode
of care; bundled care includes all the services for a specific episode of care across
the continuum (pre-acute, acute and post-acute) for a defined time period (Jacobs
et al. 2015; American Medical Association 2016). As the team completed the
value stream mapping and built the model, seven core elements were identified
and tested in the pilot. It is noteworthy that the overarching mindset and culture
fostered were “make it work for the patient,” in addition to a low rules environ-
ment to encourage and facilitate innovation.

Intervention
St. Joseph’s Health System ICC Program
The St. Joseph’s Health System (SJHS) (St. Joseph’s Health System 2016) includes
a multisite acute teaching hospital (St. Joseph’s Healthcare Hamilton [SJHH]),
a community hospital (St. Mary’s General Hospital [SMGH]) and a home care
provider (St. Joseph’s Home Care [SJHC]), which positioned it well to demon-
strate and evaluate bundled care and payment.

To test the model, four clinical streams of patients were selected: thoracic
surgery, joint replacements (hip and knee), chronic obstructive pulmonary
disease (COPD) and congestive heart failure (CHF). A new bridge was built

Box 1. Principles to guide healthcare transformation in Canada
1. Enhance the healthcare experience

• patient-centred; and
• quality.

2. Improve population health
• health promotion and illness prevention; and
• equitable.

3. Improve value for money
• sustainable; and
• accountable

36 Nursing Leadership Volume 30 Number 1 • 2017

between the hospital and home care teams, with the new role of an Integrated
Care Coordinator being that of acting as the connective tissue and bridge for
each clinical stream. Three streams were led by Registered Nurses and one by
a Physiotherapist.

Within each stream, the hospital- and community-based healthcare workers most
intimately involved in providing care are brought together with patients they serve
to redesign the process of care, which is delivered by two sectors and frequently
characterized by a lack of coordination. ICC then combines the clinical teams, the
clinical care and the client record into a single program to best serve the client’s
needs. ICC also shifts specific clinical activities to the most effective setting, typi-
cally shifting care from hospital to home, and further adds value by providing
patients and families with 24/7 1-800 telephone support. The ICC model contrasts
with the standard model, in which patients’ care is delivered by multiple organiza-
tions and providers (including hospital, community care access centres and home
care and community providers), with multiple transitions (Figure 1).

The model was envisioned as one in which rapid cycles of change and improve-
ment were expected, and the model would evolve in response to emerging
evidence and data. Consequently, planning and implementation overlapped, and

Figure 1. Comparison of standard model of care and ICC model of care

CCAC = community care access centre; ED = emergency department; ICC = Integrated Comprehensive Care;
QBP= quality-based procedures.

ICC model

Home care
provider

CCACHospital Community
provider

Single collaborative clinical team

Single integrated care path (hospital to home)

Single medical record

Single point of contact

Team

Record

Process

(± QBP, order
sets, discharge

bundle, care
path)

Team

Record

Process

Individual
providers

Record

Process

Primary care
provider

Specialist

Outpatient
clinic

Community
health centres

Unplanned
ED visit or

readmission?

H
a

n
d

o
ff

–
n

ew
e

p
is

o
d

e
o

f
ca

r
e

H
a

n
d

o
ff

–
n

ew
e

p
is

o
d

e
o

f
ca

r
e

H
a

n
d

o
ff

–
n

ew
e

p
is

o
d

e
o

f
ca

r
e

H
a

n
d

o
ff

–
n

ew
e

p
is

o
d

e
o

f
ca

r
e

Standard model

37Integrated Comprehensive Care – A Case Study in Nursing Leadership and System Transformation

challenges were addressed, and the model was refined in real time. The imple-
mentation of the first ICC patient streams occurred within two months and, as
the evaluation data later showed, the ICC clinical teams were handily outperform-
ing (e.g., shorter hospital stay, fewer readmissions and ER visits and cost savings)
the pre-ICC system of care (Shargal et al. 2015).

Within a few weeks, the project lead and steering group reported that nursing staff
were designing and redesigning aspects of their work as they implemented the
model. Furthermore, they were solving complex design issues that had seemed
insurmountable in the pre-implementation phase, which began to define one of the
central characteristics of the ICC model – the importance of point-of-care innova-
tion and empowerment. For example, real-time charting using technology (tablets)
and an integrated electronic medical record (EMR) to ensure all team members
were informed of each other’s assessments and visits with patients, and the develop-
ment of a 24/7 telephone line to support patients when they had concerns, which
was further supported by the EMR that allowed the ICC team member to review the
patient’s history and future home care team visits. In collaboration with the inter-
professional team members involved in patients’ care, nurses and other colleagues
in coordinator roles developed an integrated approach to patient care that contin-
ues to generate positive outcomes for our patients. By the end of 2012, SJHS had
successfully piloted the four ICC clinical streams, which had:

• delivered on clinical outcomes, patient satisfaction and value;
• successfully broken down real and perceived funding barriers; and
• enabled rapid implementation and identified key elements/success factors (Box 2).

The first ICC streams were implemented at SJHH in Hamilton, a community
with teaching hospitals and a university faculty of health sciences, and it served
patients from across the Hamilton Niagara Haldimand Brant LHIN. In 2013, the
ICC Steering Committee endorsed a plan to expand and test the model with a
community hospital (SMGH in Kitchener) and home care provider (SJHC) for
four clinical streams (thoracic surgery, cardiovascular surgery, COPD surgery and

Box 2. The ICC key elements/success factors
1. Client-centred care to promote client empowerment and active engagement.
2. Integrated care coordinators who would follow clients across the continuum of care.
3. Integrated interdisciplinary teams innovating during implementation and then standardizing care

pathways that span hospital and community.
4. Use of shared electronic health record which would also serve as a hub for communication.
5. Use of simple and available technology to provide flexibility in communication.
6. Community-based 24 hours a day, seven days a week access to medical care.
7. Flexibility in the delivery of care in hopes of continually improving the processes of care.

38 Nursing Leadership Volume 30 Number 1 • 2017

CHF surgery). In doing so, they were also testing the impact of nursing leadership
outside of an academic setting. The findings:

• replicated improvements to clinical outcomes, satisfaction, value and rapid
implementation; and

• validated key elements/success factors (Box 2) outside of an academic centre.

Importantly, during the process of spread, a critical mass of leaders was estab-
lished (consumers, physicians, nurses, clinical, management, governance, front-
line staff ) in two LHINs, with hospital- and community-based nurses often play-
ing a pivotal role being cross-trained so that they could understand each other’s
contribution to patient care along the continuum and have confidence in each
new refinement to the care pathway.

In 2015, influenced by the positive results of the SJHS ICC pilots, the Ministry of
Health and Long Term Care (MOHLTC) issued a provincial call for expressions of
interest to test models of bundled care and funding outside of SJHS and its shared
governance model (MOHLTC 2015). SJHS, in partnership with the HNHB LHIN
CEOs, collaborated and was one of six successful projects selected to spread and
expand the ICC model to create a LHIN-wide program for COPD and CHF. By
this time, the early influence of nursing leadership had played a role in many of
the critical success factors embedded in the process of spread. Importantly, it was
understood that other professions could also assume similar leadership roles.

Results
An analysis of the thoracic ICC stream found shorter hospital stays, fewer read-
missions and ER visits and cost savings with no increase in adverse post-discharge
outcomes following a major thoracic surgery (Shargal et al. 2015).

Nursing leaders were critical to the ICC program’s ability to integrate and bundle
care across the hospital to home continuum. Nursing knowledge and exper-
tise related to providing comprehensive approaches to care including health
education, preventive care and treatment, commitment to patient-centred and
evidence-informed practice, were foundational to the program’s success. Nurses
also developed practices, integrated care paths and performance metrics on the
basis of best practices and professional standards (e.g., telehomecare standards for
responding to 24/7 telephone line calls from patients).

Nurses also played a key role in building a culture of collaborative interprofes-
sional practice, which enabled cross-training and relationship-building amongst
all interdisciplinary team members, reducing duplication of services and visits
in the community and enhancing communication amongst team members.

39Integrated Comprehensive Care – A Case Study in Nursing Leadership and System Transformation

An example of this collaboration is the ICC virtual rounds (attended by the
ICC Coordinator and home care team), where the ICC team regularly discusses
patients’ status and care path and modifies the number, type of visit and discipline
of visits based on the interdisciplinary communication following contact/visits
with patients in the community.

In 2013, nurses participated in a focus group to evaluate the impact of the ICC on
their professional practice and job satisfaction. It is clear that this approach has
also had a beneficial impact on nurses and their practice. Nurses reported:

• greater autonomy and independence in clinical decision-making, as well as
empowerment to apply professional judgment;

• feeling much more valued as a practitioner and employee and more actively
engaged in their work; and

• a greater sense of improved trust between physicians and clinicians.

These and other findings reported in the literature offer some promise that models
such as ICC, which fully engage nurses’ knowledge and skill in their professional
practice and invite leadership and collaboration with patients, families and inter-
professional colleagues, may also help to retain them. Banner et al. (2010) reported
that “nurses are eager to embrace new practice roles” and that their eagerness
is associated with enhanced job satisfaction and improved retention.

Discussion
As the health system continues to transform and adapt, nurses are uniquely
positioned to be leaders in this transformation. Nurses will also need to adapt
and assume new roles within a changing system (Holt 2008; Banner et al. 2010).
Transformation also provides nurses with opportunities to expand current roles,
customize services to meet population needs and maximize scope of practice
(Banner et al. 2010). These transformations are likely to include new quality-based
procedures (MOHLTC 2016), funding model changes and structural changes in
community and primary care, as well as future innovations not yet imagined.

While system transformation may bring uncertainty, it will undoubtedly also
provide opportunities for leadership, greater engagement and the potential for
improved patient, provider and system outcomes. Our experience with ICC
suggests that there are important questions to consider as we move towards
a more integrated system that puts patients first:

1. Have we fully considered the roles that nurses will play as formal and infor-
mal leaders in an integrated system and are we creating the right conditions
to develop those roles?

40 Nursing Leadership Volume 30 Number 1 • 2017

2. Are we recognizing the importance of nursing leadership as a critical success
factor for successful system integration?

To transform the system in the best interests of the patients we serve, nurses must
be engaged as leading forces for change. Their knowledge, skill and expertise
must be leveraged to ensure that system improvements are realized and sustained,
and practice environments must enable nurses to work to full scope of practice
and to implement best practices.

The ICC model of integrated and bundled care yielded the following
leadership lessons:

• The ICC nursing role included formal and informal leadership roles within
the interdisciplinary team, which was nurtured through ICC structures such as
virtual rounds, one-to-one connections with team members regarding patient
needs and team meetings. This contributed to the success of the ICC model by:
– reducing hospital length of stay by transferring care to the community with

nurses trained and experts in post-acute care for the specific disease streams; and
– preventing readmissions by fully engaging with the entire interprofessional

team in a collaborative practice model.
• Key enablers were put in place to facilitate full scope of practice to improve the

process of care. This included mentorship roles for nurses with ICC experience,
which was central to rapid training and development of new hires and to ongoing
professional development to enhance quality care.

• The ICC model required the development of new documentation systems, a
single medical record and the use of simple communications technologies such
as tablets and phones. Nursing leadership was essential for these processes to be
developed in a manner consistent with professional standards and best practices
and to support continuity of care across the continuum.

• It takes time, structures and much effort to build a team that spans acute care
to home care.

• Barriers and challenges:
– Potential impact of current labour rate gaps between hospital and community

nurses, and how best to narrow this gap to integrate care and teams across
the continuum.

– Importance of integrated medical records with real-time documentation.
• Resources and time to support:

– A fulsome orientation to the model, philosophy, goals and desired outcomes.
– Training to ensure skill and expertise to care for patients in the ICC clinical

streams (e.g., COPD care and action plans).
– Shadowing of interdisciplinary team members to understand each other’s

roles and areas of expertise.

41

– Team-building activities.
– Mentorship (e.g., participation by all interdisciplinary team members on ICC

virtual rounds provides opportunity for teaching and learning; RNs providing
consultation support to RPNs).

As we look to the future, it is important to reflect on how we can prepare
nurses so that they are poised to play these critical leadership roles in system
transformation. We would suggest that thought be given to the following:

• Nursing education: The ICC program showed the need for integrated teams
with a culture of team work, openness and respect. The Future of Nursing:
Leading Change, Advancing Health (IOM 2010) report outlines several barri-
ers that prevent nurses to effectively respond to the evolving and rapidly
changing healthcare environment, and it highlights the need for higher
levels of education/training for nurses with a focus on “leadership, team-
work and collaboration, system improvement, health policy, community,
and evidence-based practice.”

• Designing and delivering client-centered care: Nurses have a key role in ensur-
ing that clients and their families are included in the design of any new model
of care. Clients set the priorities and drive the change that’s required to better
support their needs and design a more efficient system. They should have access
to the team when they require support, and we must ensure the system is easier
to navigate.

• Clear vision for change and transformation: Nursing leaders must play a key
role in envisioning and enabling a new way forward that includes building
bridges between organizations at the point of care, and helping to prevent “turf
wars” that negatively affect patient care. From the outset of implementation
of the ICC program, there was a very clear vision developed by the Healthcare
Team, which included:
– improve the client experience;
– reduce waste in the system;
– improve provider and information continuity; and
– ensure clarity of roles and accountability across the continuum of care.

Ultimately, that vision and the results it delivered trumped turf concerns
as the ICC model spread. Without that clarity of vision in the day-to-day
implementation and operation of ICC, it is doubtful that the model could have
spread successfully.

Correspondence may be directed to: Laura Wheatley, 50 Charlton Ave East,
Hamilton, ON, L8N 4A6; e-mail: [email protected]

Integrated Comprehensive Care – A Case Study in Nursing Leadership and System Transformation

42 Nursing Leadership Volume 30 Number 1 • 2017

References
American Medical Association. 2016. Bundled Payments. Retrieved September 27, 2016. <http://
www.ama-assn.org/ama/pub/advocacy/state-advocacy-arc/state-advocacy-campaigns/private-payer-
reform/state-based-payment-reform/evaluating-payment-options/bundled-payments.page>.

Banner, D., M. MacLeod and S. Johnston. 2010.” Role Transition in Rural and Remote Primary
Healthcare Nursing: A Scoping Literature Review” CJNR 42(4): 40–57.

Canadian Nurses Association. 2013. Registered Nurses: Stepping Up to Transform Healthcare.
Retrieved April 28, 2017. <https://www.cna-aiic.ca/~/media/cna/files/en/registered_nurses_
stepping_up_to_transform_health_care_e.pdf?la=en>.

Canadian Nurses Association and Canadian Medical Association. 2011. Principles to Guide
Healthcare Transformation in Canada. Retrieved April 28, 2017. <https://www.cna-aiic.ca/~/media/
cna/files/en/principles_to_guide_hct_e.pdf?la=en>.

Holt, I. 2008. “Role Transition in Primary Care Settings.” Quality in Primary Care 16: 117–26.

Institute for Medicine (IOM). 2010. “The Future of Nursing Leading Change, Advancing Health.”
Report Brief October 2010. Retrieved September 6, 2016. <http://www.nationalacademies.org/
hmd/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Future%20of%20Nursing%20
2010%20Report%20Brief.pdf>.

Jacobs, J., I. Daniel, G. Baker, A. Brown and W. Wodchis. 2015. Bundling Care and Payment: Evidence
from Early Adopters. Health System Reconfiguration. Toronto, ON: University of Toronto.

Ministry of Health and Long-Term Care (MOHLTC). 2015. Bundled Care (Integrated Funding
Models). Retrieved September 27, 2016. <http://health.gov.on.ca/en/pro/programs/ecfa/funding/
ifm/default.aspx>.

Ministry of Health and Long-Term Care (MOHLTC). 2016. Health System Funding Reform: Quality
Based Procedures. Retrieved November 16, 2016. <http://health.gov.on.ca/en/pro/programs/ecfa/
funding/hs_funding_qbp.aspx>.

Shargall, Y., W. Hanna, L. Schneider, C. Schieman, C. Finley, A. Tran et al. 2015. “The Integrated
Comprehensive Care (ICC) Program: A Novel Home Care Initiative after Major Thoracic Surgery.”
Seminars in Thoracic and Cardiovascular Surgery 28(2): 574–82. doi:10.1053/j.semtcvs.2015.12.003.

St. Joseph’s Health System. 2016. Retrieved September 27, 2016. <http:// www.sjhs.ca/>.

HealthcareQuarterly.com