HomeColumnsFrom the CEO's DeskSupporting the quest to live fully

Supporting the quest to live fully

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Contending with severe allergies and asthma for decades now, Pat Schmidt is a regular at St. Joseph’s Hospital in London, visiting outpatient clinics as often as every two weeks.  Here, she receives specialized care to control her symptoms, but, if you ask her, that’s not what impresses Pat most about the clinics.

“I am treated like family.  They all know my name and whenever anyone sees me, they always have a smile and say hi and ask how I am. When I call in for an unscheduled appointment, they accommodate me. If I ever have questions, they make sure they get the answers for me and they take the time to talk to me about my concern.”

Pat’s experience – the personal touch and education she receives, the focus on supporting self- care, and integrated care that meets her varied needs – are the goals for chronic disease management at St. Joseph’s Hospital.

On October 10, 2013, the hospital officially opened a new, 42,000 square-foot central outpatient area purpose built for the treatment of complex medical and chronic disease. This opening represents an important juncture and a new era for St. Joseph’s Hospital brought about by a 15 year-odyssey of hospital restructuring and renewal in London. The hospital, one of five sites that make up St. Joseph’s Health Care London, has made the transition from acute inpatient care to specializing in minimally invasive short stay and day surgery, and outpatient treatment of complex medical and chronic disease. With this new role, and an innovative philosophy and approach to providing care, St. Joseph’s is redefining what it means to be a hospital.


Chronic disease management is a critical area of focus whose time has come. One in five Canadians is living with chronic disease and the numbers are growing. So too is the burden of chronic illness – on people’s lives, the economy, and on the health care system. Chronic illness financially accounts for 87 per cent of disability costs and consumes 67 per cent of direct health care costs.

St. Joseph’s Hospital is home to a broad range of ambulatory medicine programs for chronic disease with a common goal – to provide and coordinate care in new ways focused on each person’s multiple, complex continuing needs and individual priorities. This means recognizing that patients are coming to us with more than one chronic disease that requires team work across programs, across sites, and with our community partners. It means multiple appointments on the same day during the same visit and finding new ways to deliver care that improves access, outcomes and quality of life for patients. It means truly understanding the patient experience.

This takes a fundamental shift in health care delivery for chronic disease and we are taking those steps. Our commitment is entrenched in our strategic plan – integrated chronic disease management is one of three areas of clinical focus for our organization. This means teams are provided the capacity to do this important work. A Medicine Services Chronic Disease Management Planning Team has developed a model of care based on the Chronic Care Model (CCM). This conceptual model has been adopted as the basis for planning chronic disease management services worldwide. It addresses issues such as adherence to practice guidelines; care coordination; follow-up to improve outcomes; and patient education to help individuals self-manage their illnesses.

A survey of our ambulatory medicine clinics was conducted to assess our adherence to the CCM model from the patient perspective. The Patient Assessment of Chronic Illness Care (PACIC), a standardized measure of care delivery, was used. While our programs rated well against comparators, there is work to be done. These results now serve as a baseline to address and evaluate improvements to care as our new model of care is implemented.


It’s a significant undertaking. The ambulatory medicine programs at St. Joseph’s Hospital, which serve a vast region of Southwestern Ontario, see a combined total of about 84,000 patient visits each year. In addition to new models of care delivery, other components of our focus on chronic disease management include teaching, research to improve outcomes, and region-wide collaboration to improve the health care system.

There have been some exciting, early accomplishments. A new, robust referral process has been implemented in our Pain Management Program to improve our response time. This includes a single, standardized referral form and consistent triage process. Also implemented were reminder calls for patients and a protocol for unconfirmed appointments to be filled with patients on a call list. As a result, we have seen a 10 per cent increase in the number of new patients over the same period last year. The reminder calls are a major contributing factor, reducing the ‘no show’ rate for new referrals by a staggering 60 per cent and allowing access to more new patients.

For patients with pituitary disease, St. Joseph’s created the One-Stop Pituitary Clinic in collaboration with specialists across the city. Through a central referral process, initial lab testing, endocrinology consult, visual field testing and neuro-ophthalmology consult are arranged on the same day.  In the past, patients with pituitary disease from across the region made on average 2.4 trips to London travelling a total distance of about 300 km. The total number of visits has since dropped to one and the average distance to 116 km.


In November 2013, St. Joseph’s and about 80 regional health care stakeholders from a wide variety of sectors gathered for the London Partnering in Health Care Transformation/Health Links event to discuss ways to better serve high-needs patients at this time of rising health care costs. Since then, the province’s Health Link model launched in London of which St. Joseph’s is a committed partner. Health Links encourage greater collaboration between family care providers, specialists, hospitals, long-term care, home care and other community supports. The goal is for patients to spend less time waiting for services, improve patient transitions within the health care system, and have care providers working together to develop solutions that address each patient’s specific needs.

The approach is a good fit with our own goals of integrated, interprofessional care, not only at St. Joseph’s Hospital but across the organization at Parkwood Hospital, Regional Mental Health Care, Mount Hope Centre for Long Term Care and the Southwest Centre for Forensic Mental Health Care. We are creating synergies between experts from various fields and bringing them together to collectively focus on patient needs. Through our new Centre for Cognitive Vitality and Brain Health, for example, geriatricians, psychiatrists, physiatrists, psychologists, scientists and others are working collaboratively to provide care and improve outcomes for those with mental illness, dementia, brain injury, and other neurological conditions.

With an enduring commitment to rise to new challenges and a willingness to go in new directions, the ultimate goal is to earn complete confidence in the care we provide and make a lasting difference in the quest to live fully. It’s to create experiences like that of Pat Schmidt.


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