Complex Care Program

The Complex Care Outpatient Program is a partnership between CHEO, local community organizations and Complex Care 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. Additionally, each child has a unique medical care plan called a SPOC (Single Point of Care) that is updated on a regular basis. This structure ensures proactive and continuous coordination of care. The program fosters team work and collaboration through regular family focused team meetings (interdisciplinary teams, both hospital and community based) so that everyone works as “one team” to support parents' identified goals.

In 2020, our Complex Care Partnership Program celebrated it's 10 year anniversary!

The Complex Care Program was co-designed with families and community partners in 2009-2010. Over the past 10 years this program has helped improve access to and coordinate care for children and youth who are medically complex, fragile and technology dependent.

Visit our KudoBoard to learn more about some of the accomplishments, fun moments and great partnerships that have taken place over the past 10 years.

Mission statement

We help children and youth with medical complexities (CYMC) and their families to be their healthiest.

Program goals

1. 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
2. Advocate and arrange for services that promote the best possible health and development for children and youth
3. Provide the right care, at the right place, at the right time, for the best use of healthcare services.
4. Ensure access for CYMC to the Complex Care Program services
5. Support and empower families as equal partners as they navigate the system, helping them to access resources and services
6. Promote clear and easy communication between families and healthcare team members

Contact

Please call our Administrative Assistant for any questions about the program at 613-737-7600 x3838.

Referral form and criteria information

Referral form

Mail or fax the form to:

Complex Care Program
Room 2011
CHEO
401 Smyth Rd.
Ottawa ON K1H 1L1

Fax: 613-738-4251

We accept referrals for:

• Multicomplex child (see complexity criteria)
• Medically fragile (see fragility criteria)
• Dependency on high intensity care/technological device
• Has an existing risk of an unexpected severe acute life-threatening event.
• Child is under 16 at the time of referral
• Child has a primary care provider that will remain actively involved in patient's care
• Child has an unmet need for care coordination

We do not accept referrals for:

• Child is over 16 years of age at the time of referral
• The medical condition(s) of the child fit into a pre-existing team health care providers offering coordination of care between all required a service providers (example: Eating Disorders OPT, Psychology, Psychiatry, Dermatology, PT/OT, Cystic Fibrosis Rehab Med, Spina Bifida, Oncology)

More Information

Learn more about how to provide complex care at home for children and youth.