Catalogue of Canadian Complex Care Programs and/or Organizations Providing Services to CYMC

Last modified by Lisa Stromquist on 2017/09/14 21:14

This list represents the programs and organizations that have supplied their information to CAPHC and is not an exhaustive list of complex care programs and services in Canada.

Level of Care



Organization
Contact information
Name of Program and Brief Description  
Community Health Care Rotary Flames House

No Complex Care Program but provides services through:

Children's Hospice and Palliative Care Service

A specialized palliative care service ( ambulatory and hospice/respite)  which provides services to children with medical complexity when severity is such that it wouldn't be surprising if they died sometime in childhood. 

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Community HospitalNorth York General Hospital, North York, OntarioPaediatric Complex Care Clinic
The Paediatric Complex Care Clinic provides centralized, full-service care, close to home. North York General Hospital is the fourth hospital in Ontario to introduce the one-stop model for complex care in paediatrics. The Paediatric Complex Care Clinic team delivers excellent, patient- and family-centered care and works towards improving the quality of life for both you and your child.
The clinic will help oversee your child's health care needs and partner with you and any health care provider involved in your child's care. The Paediatric Complex Care team will help make sure your child is getting the right care, at the right time, in your own community.

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Community HospitalTrillium Health PartnersComplex Care Clinic

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Community Health Care
Children's Treatment Centre

Children's Treatment Network of Simcoe York (CTN)

http://ctnsy.ca/

Includes:

Orillia Soldiers’ Memorial Hospital- HSC-OSMH-RVH

No Complex Care Clinic but provides services through:
Children's Complex Care Navigation Program (CCCNP) clinics are hosted in Simcoe County by Orillia Soldier's Memorial Hospital (OSMH) and Royal Victoria Regional Health Centre (RVH).

CTN supports those clinics through provision of access to CTN's shared electronic record allowing community providers involved in providing care to that patient  (rehab, service coordinators, feeding team, etc., to access the medical plan of care developed in the clinic to assist in providing appropriate integrated services. Similarly the clinic team can access the community providers information in the record to support appropriate planning.

As well CTN provides a range of rehab specialty services (feeding, augmentative communication, seating and mobility support, etc.) and other supports e.g, coordinated service planning and family support, for children enrolled in those clinics meeting the CTN eligibility criteria and in need of those services.

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Home and community health care services

Bayshore Home Health (multi-city)

Nursing Support Services

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Homecare


Alberta Health Services- Calgary Paediatric Home Care

In Patient Complex Care Team and Home Care Complex Airways Team

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Homecare



Alberta Health Services – Children’s Home Care, Edmonton, Alberta

Children's Home Care

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HomecareSaint Elizabeth

Complex Care/School Support Nursing and Rehabilitation Services

No Complex Care Clinic but provides services at school and at home through the Child and Family Program - Provides evidence-based integrated care to families with infants, children and youth from birth to the age of 18.  We deliver quality paediatric care focused towards enabling and maximizing independence in the environment best suited to the child’s and family’s needs in the home, schools, group and community residences.

 The provision of paediatric care at SE has many different focuses that include: health maintenance – provides care allowing children to remain independent and at home restoring to previous health states and palliative care to children and their families from birth to 18 years of age. Specific care within these focuses include infusion therapy, wound care, complex care, maternal-newborn care, chemotherapy, respite, nutritional support , developmental and respiratory care. Services are provided by an interdisciplinary team that includes nursing, personal support  and rehabilitation therapists. The SE Paediatric therapeutic program includes client health improvement interventions with a focus on skills development and education for clients, families, and caregivers.

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Community through Education


Alberta Health Services, (led by Alberta Education)

CY CN - Children and Youth with Complex Needs (cross system initiative: health, children’s services, education)


Rehab



BC Centre for Ability Vancouver, BC

http://www.bc-cfa.org/

Provides therapy services as part of BC Child Health program

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RehabChild Health Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba

Rehabilitation for Children

To help families with care co-ordination

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RehabOttawa Children’s Treatment Centre, Ottawa, Ontario
http://www.octc.ca/

Partners in the Champlain Complex Care Program led by CHEO

Rehab

Sunny Hill Health Centre (affiliated with BC Children’s)

BC Childrens Sunny-hill-health-centre/about

Not specifically referred to as a complex care program.  CMC use acute rehabilitation (inpatient) and neuromotor programs (outpatient/outreach) 

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Rehab

Holland Bloorview Kids Rehabilitation Hospital

http://www.hollandbloorview.ca/Home

Complex Care Neuromotor NP Clinic & Complex Rett Syndrome Pathway outpatient clinics

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Rehab Wascana Rehabilitation Centre, Regina Qu'Appelle Health Region, Regina, SK.

No complex care clinic but services are provided within developmental pediatric clinics in the Rehabilitation Hospital

Children's Program provides multi-disciplinary assessment, treatment and follow-up in an Outpatient setting.  Visiting pediatricians provide minimal medical input to stable children. 

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Tertiary


Alberta Children's Hospital

Complex Care Team

Tertiary



BC Children’s Hospital Vancouver, BC

 

The Complex Care Program is based at the tertiary care center. There is partnership with community providers, but no established outreach, telehealth or community-based programs at this time

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Tertiary



Children’s Hospital of Eastern Ontario, Ottawa, Ontario

http://www.cheo.on.ca/en/Champlain-complex-care

Champlain Complex Care Program

Since 2009, the Champlain Complex Care Program has been collaboratively working with hospital and community partners to provide family centered care and care coordination to children and youth who are medically complex, fragile and technology dependent. Based on their specific needs, each child/youth will be assigned to a Family Coordinator and Most Responsible Physician (hospital or community based).

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Tertiary

CHU mère-enfant Ste-Justine, Montreal, QuebecComplex care program
Multidisciplinary team providing care coordination for children with complex and chronic medical conditions

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Tertiary


IWK Health Centre

There is no complex care clinic services are provided by:

Each general paediatrician dedicates one of their clinics/month to focus on their complex patients.  One paediatrician takes on many of the complex patients.  We have 1.0 FTE Clinical  Nurse Specialists (job shared by 2 people) who focus on complex and medically fragile children/youth.

Falls under general paediatrics.  As described above, each of the paediatricians has one day/month dedicated to their complex patients. CNS hosts complex respiratory rounds monthly with respirology, ENT, paediatrics, SW, respiratory therapy, continuing care (home care) to review the complex respiratory patients in regards to their disease, management, and long-term plans.  One CNS works closely with the GI team with the children with intestinal failure.

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Tertiary

Janeway Children's Health and Rehabilitation Center

No designated program name. We have multiple clinics and services which are coordinated through designated specificity nurses. Each child's care is organised by Specialty RN which is most appropriate based on primary diagnosis. This is done in consultation with other services as needed.

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 Tertiary

London Health Sciences Centre, London, Ontario

Children’s Hospital for Medical Management

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Tertiary

McMaster Children’s Hospital, Hamilton, Ontario 


Tertiary
Montreal Children’s Hospital, Montreal, Quebec .
Complex Care Service, Montreal Children’s Hospital

Intensive Ambulatory Care ServiceTo provide safe, effective and family-centered care to children with medical complexity, on a short, medium or long term basis, in their own home environment

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Tertiary


The Hospital for Sick Children, Toronto, OntarioPediatric Medicine Complex Care Program
Complex Care Respiratory Clinic

 Sick Kids Complex Care Program includes a complex care clinic, partnership with 4 satellite programs at community hospitals (SickKids NP with shared FTE between satellite clinic and SK clinic) and an inpatient consult service.  Our program currently supports approx. 250 patients and families.
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 TertiaryStollery Children's Hospital

No designated complex care clinic.

Children with medically complex conditions receive services in specific clinics and with specific subspecialist e.g. Pediatric Respirology runs trach clinic, home ventilation clinic (multidisciplinary clinic including community home care and respiratory providers); Pediatric Cardiology has specialized clinics and services for children with ventricular assist devices (VADs) or Berlin Heart,  specialized care and follow-up for children receiving anticoagulation therapy (KidCLOT), for children with Pulmonary Hypertension and for heart transplant patients.    Pediatric nurse practitioners follow children with complex medical and surgical problems-- facilitating continuity of care.  Stollery Children's Hospital programs work closely with Home Care Children's Team for complex care planning, transition, etc.



Tertiary

Child Health Program, WRHA Winnipeg, ManitobaWe have a pediatric special care unit with a nurse clinician assigned to this area. The nurse clinician is responsible for coordinating the care of the complex technology dependent children within this unit. If the child enters the hospital with a tracheostomy and feeding tube they may be admitted to an inpatient unit. Often it is the CRN from that unit that helps to coordinate services and care for that patient.
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Created by Lisa Stromquist on 2015/01/29 17:35