Champlain Complex Care Program

Last modified by Ann Watkins on 2016/03/31 23:21


  • Provide a family-centered approach 
  • Facilitate communication and collaboration among care providers
  • Coordinate the child/youth and families needs across home, community and hospital services
  • Relieve the burden of care coordination on families
  • Improved overall satisfaction
  • Reduce duplication of services
  • Improved health statusr
  • educed ED visits
  • reduced inpatient Length of Stay (LOS)
  • reduced events of hospitalization
  • Improved family health

Services/activities that help to meet the objectives

Service Delivery Model*

Based on individualized care needs of each child/youth


  • To provide individual care plans for all participating children/youth and families
  • Increase appropriate throughput
  • Provide services to a larger group of clients.

Patients will be assigned one of three Care Delivery Levels based on completion of:

  • Inclusion/Exclusion Criteria
  • screening
  • Discussion with referring physician
  • Child and Adolescent Needs and Strengths (CANS) Assessment
  • Single Point of Care (SPOC) document

Patients may move from one level to another as needs change

Typical patient ( ie. diagnoses, age, technology)

  • Technology dependent and/or use of high intensity care
  • Fragility, chronicity, complexity
  • Not receiving similar intensive care coordination and system navigation services from another group
  • Services for children who have an existing risk of an unexpected severe acute life threatening event
  • Has or is at risk for a mental health diagnosis
  • Between the 0-16 years of age

Inclusion criteria

Level I
Acute illness/ chronic life-limitingMDU/ED/frequent hospitalization

Level II
Complex/medical fragility hospitalization/ED reduced or rare

Level III
Complex/medical fragility

hospitalization/ED minimized or not required

Exclusion criteria.

Team constituent or organizational structure


  • Case Managers
  • Family Coordinator (6)
  • Home and School Teams
  • Allied Health


  • MRP
  • Nurse Care*
  • Coordinator/FC (14)
  • Nurse Practitioner*
  • Project Manager*
  • Research Inst*
  • Social Workers
  • Allied Health 


  • Nurse Case Managers
  • Family Coordinator (1)
  • Social Workers
  • Allied Health
  • Liaison Teachers
  • Child/Youth/Family, Community MD, Rogers House,

MCYS The Program Team Structure 

Most Responsible Physician

CHEO – 2+

Community - Several

Nurse Care Coordinator

CHEO – 2 

Community - Several (CCAC/OCTC in kind service)

Data Coordinator/RI Support (PT)

Nurse Practitioner (PT)

Other in kind services – SW, RD, OT,PT, SLP

Program funding

Program evaluation


Example: Are the activities of the Pilot Project being implemented as intended?


Example: What factors prompt families to participate in the Pilot Project?


Example: Are families and staff satisfied with the activities and services of the Pilot Project?

Health Service Utilization & Resource Use 

Example: Is there a reduction of hospitalizations and emergency room use after entry into the Pilot Project?

Health Status 

Example: What impact do the services of the Pilot Project have on participating children, youth and their families?

Clinical research

Created by Lisa Stromquist on 2015/09/03 20:26