Connecting Care to Home program profiled internationally


September 21, 2017

London, ON – Connecting Care to Home (CC2H), a new local collaborative program aimed at integrating patient care between hospital and home is gaining the attention of European researchers and health care providers. The model is the result of a collaboration between the South West Local Health Integration Network, London Health Sciences Centre, St. Joseph’s Health Care London and the Thames Valley Family Health Team.

Results of the program, launched in Oct 2015, are significant. Hospital length of stay is roughly 54 per cent shorter, hospital readmissions are down by almost 60 per cent, and the total cost per patient to the health care system has declined by almost 50 percent.

Based on CC2H’s success, Donna Ladouceur, South West LHIN Vice President of Home and Community Care, has been invited to present the innovative care model to researchers at the first Annual European eShift research conference in Paris, France this month. All expenses are supported by the National Health System.

CC2H works by engaging patients, and ensuring that hospital, community and family physicians are working together to support the best care possible for those with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), a patient population with high rates of emergency department visits and hospital readmissions.

Education and technology are key components of this program. Upon discharge, patients are provided with educational materials and 24-hour access to registered nurses through a live answer line. Home care services are administered by the Victorian Order of Nurses under the direction of designated registered nurses.

Ontario Telehealth Network enables videoconferencing before and after discharge so that all members of the care team can virtually meet with patients and family members. Also, all care providers in contact with the patient have 24-hour access to a single patient file that is updated in real-time. This allows continuous access to the most up-to-date and accurate information of a patient.

For Doug Limb, being a CC2H patient means feeling a sense of comfort, confidence and security to know that he has access to a care provider at any time of the day or night. He now finds that managing his chronic condition has become “second-nature,” learning new skills from the comfort of his home.

CC2H has also been recognized nationally as the recipient of the 3M Health Care Quality Team Award. Recognition is based on three elements: innovation, quality and teamwork. This model was built on the success of the eShift program supporting medically fragile children and palliative patients at home. Partners are now looking at ways to expand the program to possibly support those with other chronic conditions and to treat mental health.



“In knowing that patients with COPD often present in emergency departments as a result of anxiety or not knowing how to manage their chronic condition, we knew that we had to come together as system partners to find a solution. This model truly exemplifies collaboration and provides patients with the tools and support they need to live well in their homes. We will continue to explore opportunities to build on its success for other patient populations.”

- Donna Ladouceur, Vice President of Home and Community Care, South West LHIN


“We are proud that this model developed in the South West is receiving recognition both nationally and internationally. Our LHIN has led the way in supporting technology enabled models of care over the past number of years. CC2H exemplifies the way care can be creatively designed to meet patients’ needs, both through collaboration and by leveraging technology.”

- Michael Barrett, CEO, South West LHIN


“This model allows physicians to provide continuous support both pre- and post-discharge empowering patients to feel more confident in managing their chronic condition. It also shows how successfully we can work together to improve the quality of life for those with chronic conditions.”

- Dr. James Lewis, Respirologist, St. Joseph’s Health Care London


"The CC2H program is a great example of LHSC working with our partners to implement new and innovative methods to improve the patient experience. Patients are identified in hospital and invited to join the program, which looks at the whole continuum of the patient journey. There’s a good hand-off between the hospital and community care providers, making care seamless.”

- Laurie Gould, Chief Clinical and Transformation Officer, London Health Sciences Centre


“This is a program that I feel really strongly about because I think it could help a lot of people. Had this program not existed, I would still be in the hospital.”

- Doug Limb, CC2H Patient 




For more information:

Faadia Ghani
Communications Advisor