Complex Care Program

The Complex Care Outpatient Program is a partnership between CHEO, local community organizations and Complex Care families to provide care coordination, psychosocial support and system navigation 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.

As part of the Complex Care team, your child/youth and family may also be supported by a Registered Dietitian, Social Worker, Psychologist, Family Resource Worker, System Navigator and/or Parent Navigator. 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 teamwork 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. 

Mission statement

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

Program goals

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 access for CYMC 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
Promote the social and emotional health of families
Help families to access and navigate key supports and services
Identify system gaps and find solutions to problems families often face

More about Complex Care at CHEO

Psychosocial and System Navigation Support

In addition to medical care, patients with medical complexities and their caregivers often benefit from psychological and social supports. We know that navigating the system can be overwhelming. That's why the Complex Care program has a variety of team members to supporting you through this journey.

Your nurse coordinator can connect you to: 

Social Worker: Provides support and counseling to parent/caregivers by addressing social, emotional, and financial needs, ensuring access to resources and services and support, as well as providing advocacy in navigating the medical system. Focus on clinical issues related to the impact of being a caregiver/parent to a child with a medically complex and fragile condition, loss and grief, medical trauma, adjustment to illness, coping and self-care strategies and mental health needs.

Psychologist: Offers psychological consultations, diagnostic assessments, short-term psychotherapy/interventions with patients (and their parents). Focus on clinical issues impacting medical/health care, including adjustment to illness, treatment adherence, procedural anxiety, medical trauma, pain management, functional conditions (e.g., mind-body connections) and mental health needs.

Family Resource Worker: Supports and empowers families by educating them on available community resources, assisting with navigating and completing applications for services and funding (e.g., housing, food assistance, childcare subsidies). Provides advocacy, referrals, and follow-up support to ensure access and continuity of care. Collaborates with community agencies and service providers to address barriers and promote family well-being

System Navigator: Assists patients and families in navigating the healthcare system, helping them access services, understand processes, and coordinate care among various providers. Additionally, the navigator focuses on supporting the transition to adulthood by connecting patients to appropriate resources and services as they move into adult care.

Parent Navigator: With personal experience navigating the challenges of a child with complex needs, the Parent Navigator supports parents and caregivers of children in complex care by providing guidance, peer support, and assistance in accessing caregiver-focused resources and services. Additionally, the Parent Navigator cultivates a strong community of support for families through social gatherings, wellness events and educational workshops.

Complex Care satellite clinics

Complex Care Kids Ontario (CCKO) is a provincial strategy with the aim to expand the capacity of existing complex care clinics and establish additional regional clinics to provide complex care to extremely high need children and youth across Ontario.

Visit Complex Care for Kids Ontario (CCKO) for more information on complex care.

Timmins Satellite Clinic

Learn more about the northern Complex Care Satellite program partnership with the Timmins District hospital, Cochrane Temiskaming Children's and CHEO.

Montfort Satellite Clinic

CHEO has also partnered with the Montfort Pediatric clinic to provide care coordination with a NP lead model of care. To refer to any satellite clinics please use the referral process above.

Activities and groups

It's important to foster connections within the community. To support families, we regularly host virtual groups where parents can connect, share experiences, and build meaningful relationships.   

We also host a variety of activities on a monthly, quarterly and annual basis to bring families together and strengthen our community bonds. For the latest updates and details, we invite you to explore our monthly newsletter as well as our Facebook and Instagram pages.   

We look forward to seeing you and sharing these enriching experiences together! 

Navigator Program | Ottawa ON | Facebook

Navigator Program_ Ottawa (@navigatorprogram_ottawa)

Resources

Homepage - Ontario Caregiver

Changing Your Lens: Connecting Care for Children with Medical Complexity Practice Network - Children's Healthcare Canada

Supporting Families | Family Services Ottawa

Kids Come First

ACSD: Assistance for Children with Severe Disabilities Program | ontario.ca

SSAH: SSAH/ACSD

Community Health Centers Ottawa: Health Centres and Resources - Ottawa Public Health

Developmental services:

 Home - Service Coordination Support (SCS)

Valoris

Inspire SD&G | Community Support Services

ConnectWell

In the media

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
Health System News CHEO’s Complex Care Team Celebrates 15 Years of Excellence

Partner organizations

Make a referral

Referral form

Mail or fax the form to:

Complex Care
CHEO
395 Smyth Road
Ottawa ON K1H 8L1
Fax: 613-738-4251

We accept referrals for

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

We do not accept referrals:

For youth 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)

Contact us

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

More Information

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

Need more information?

Visit our online resource section to learn about a variety of health topics for children and youth and access CHEO recommended websites, books, apps, videos and more!

Resources and support