Since 2010 the Champlain Complex Care Outpatient Program, a partnership between CHEO and local community organizations have been working collaboratively with families to provide care coordination for children and youth who are medically complex, fragile and technology dependent. Each child/youth is assigned to a Nurse Coordinator or a Nurse Practitioner and a Most Responsible Physician (hospital or community-based) based on their specific care needs. Each child has a unique medical care plan called a SPOC, which is assessed in clinic “Intake Visit” and has a pro-active and anticipatory guidance in follow up clinic visits on a regular basis. The program helps foster team work and collaboration through regular family focus team meetings (interdisciplinary teams both hospital and community based) so that everyone works as “one team” to support parents identified goals.
We help children and youth with medical complexities (CYMC) and their families to be their healthiest. To do this we:
- Partner with children, youth, families and service providers in the hospital and in the community
- Ensure children, youth, and families can access the supports and services they need
- Coordinate care, ensuring that each family has a key worker with an in-depth understanding of complex care, family strengths, needs, care plans and services
- Advocate and arrange for services that promote the best possible health and development for children and youth.
- Provide the right care, at the right place, at the right time, for the best use of healthcare services.
- Ensure that CYMC have access to the Complex Care Program services.
- Support and empower families as equal partners as they navigate the system, helping them to access resources and services.
- Promote clear and easy communication between families and healthcare team members.
Families that are accepted into the program will have a key worker “Family Nurse Coordinator” to help them:
- Coordinate their child’s medical needs while they are in the community;
- Navigate their way through the health care system;
- Reduce preventable hospital visits (emergency visits and hospital admissions) through proactive coordination of care and anticipatory guidance.
We believe that this program will:
- Improve the coordination of care of children and youth with complex medical needs;
- Reduce the amount of time families spend trying to communicate with the right person;
- Improve the families experience with the health care system.
In the Media
- Watch this video to hear what families had to say about the Complex Care Program one year after it was piloted.
- Watch CTV CHEO Segments - Complex Care.
- Listen to the episode A Shot at Normal on CBC's White Coat, Black Art.
- Listen to the episode The One More Thing Mom's Club on CBC's White Coat, Black Art.
For general inquiries please contact Administrative Assistant for the program at 613-737-7600 x2365
Complex Care Kids Ontario
Complex Care Kids Ontario (CCKO) is a provincial strategy led by the Provincial Council of Maternal and Child Health that works to build a provincial standard of care for children and youth who are medically fragile and technology dependent in Ontario. The Ministry of Health and Long Term Care has funded a five-year demonstration project, through PCMCH, to expand the capacity of existing complex care clinics and establish additional clinics to provide complex care to extremely high need children and youth. The four tertiary children’s hospitals in Ontario provide regional leadership for complex care. These hospitals are CHEO, SickKids, McMaster Children’s and the Children’s Hospital, London Health Sciences Centre.
For more information about CCKO please visit: Complex Care for Kids Ontario (CCKO)
Learn more about the new northern Complex Care Satellite program partnership with the Timmins District hospital, Cochrane Temiskaming Children’s and CHEO. See links to media articles here:
- “I have found working with the Complex Care team at CHEO to be very beneficial in my work with complex care clients in the community. Collaborating with the Complex Care Team better enables me to provide appropriate support for client and families with complex medical needs in the community. Having faster access to client’s up to date medical care plan helps to facilitate a more comprehensive approach for the Champlain LHIN to provide community support”
Samara Lawrence RN BScN, Pediatric Care Coordinator, Champlain Local Health Integration Network (LHIN)
- “The Complex Care Team offers support and comfort to many clients and families. From nurses to physicians, I feel the team always collaborates with Champlain LHIN’s care coordinators in providing the most updated medical information about our clients and their health status. This collaboration has certainly lead to seamless transitions from hospital to home and/or school care. Whether for in-home or school services, equipment and respite needs, this team’s holistic approach to the child and it’s family is much appreciated and respected”
Geneviève Lafond OT Reg.(Ont.), Pediatric Care Coordinator, Champlain Local Health Integration Network (LHIN)