Strength in teamwork: Supporting patients with complex chronic illness

Imagine walking into a clinic where care feels connected. Where a team of providers collaborates to help patients build skills and confidence to manage their health. That’s the foundation of the Integrated Chronic Care Service (ICCS).

The clinic’s model is rooted in collaboration. Patients are welcomed into a team-based approach in which their needs are understood holistically, and care plans are tailored with input from multiple disciplines. The ICCS team, based in Halifax’s Parkland Professional Centre, includes nurse practitioners, registered nurses, occupational therapists, physiotherapists, clinical therapists, a dietitian, navigators and administrative staff. Together, they coordinate care, facilitate therapy groups, and support patients through their healing journey of up to 18 months.

“Every Wednesday, our team sits down together to look at the more complex cases,” said clinical therapist Jeff Pardy, who joined the team earlier this year. “It’s one of the most collaborative environments I’ve ever worked in. Everyone has a voice at the table, and we share responsibility for finding the best way forward for each patient.”

The ICCS team is already making a significant impact for patients across the province through its multidisciplinary approach. As part of that model, a physician plays an important role in the early stages of the patient pathway, supporting medical assessment and diagnosis where needed. 

Cheryl Hoddinott is the ICCS health services manager. She said welcoming a physician to the team would further enhance the circle of care already in place.

“We’re very excited about welcoming a physician to our team,” she said. “This is an opportunity to work in a collaborative, supportive environment while making a real difference for people with complex conditions.”

Pardy agreed. “Anyone joining ICCS would never feel alone here. The responsibility is shared. It’s a close-knit team that’s passionate, driven, and always learning. If someone is motivated by helping people with chronic illness and wants to work in an environment where their wellbeing and sustainability are also cared for, this is the place.”

Patients often arrive at ICCS with symptoms that can feel invisible to others. 

Conditions like fibromyalgia or chronic fatigue syndrome are not always understood outside of clinical settings. Through orientation sessions, individualized assessments, and a mix of one-to-one and group therapies, the ICCS team creates an environment in which patients feel validated and supported. Group programs such as mindfulness, cognitive behavioural therapy (CBT)and self-regulation also provide patients with an opportunity to learn alongside others facing similar challenges.

“One of the most common things we hear from patients is that they feel isolated, that others don’t see or understand their illness,” Pardy said. “Part of the power of our group work is giving people a chance to connect with others who share their experience. It helps break down that sense of alienation.”

For Pardy, the supportive culture of ICCS is what makes the clinic unique. Since arriving, he has helped design and refresh the CBT and mindfulness programs, something he said was only possible because of the trust and encouragement of his colleagues. “From day one, I felt welcomed and respected. The team gave me the freedom to build programs in the way I felt would most benefit patients. That kind of openness is rare, and it makes this work incredibly meaningful.”

Interested in joining the team?

ICCS is currently recruiting a physician to help provide assessment and care for individuals with complex chronic conditions. To learn more about this opportunity and apply, visit: Family Medicine - Integrated Chronic Care Service - Nova Scotia Health Physician Career Opportunities - More Than Medicine.

Photo of (left-right, back row) Steve McGirr, Physiotherapist; Registered Nurse (Authorized Prescriber); Julia Rose, Occupational Therapist; Jeff Pardy, Clinical Therapist; Awab Hamodat, Clinical Lead; Pamela Stewart, Clinical Therapist; Jennifer Mosher, Occupational Therapist and (left-right, front row) Nurse Practitioner; Cheryl Hoddinott, Health Services Manager; Carolyn Whidden, Administrator;Nicolle MacEachern-Holdright, Administrator; Nurse Practitioner and Balalavanya Ranganathan, Administrator.