Children’s Hospital for Medical Management (LHSC)

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

Objective/Mandate/Goals

  • To improve the experience of CMC
  • To improve health outcomes of CMC
  • To enhance cooperation & communication between partners
  • To enable shared care planning & service delivery for CMC &their families
  • To optimize appropriate use of resources for CMC & reduce avoidable costs
  • To help families with care co-ordination


Services/activities that help to meet the objectives

  • Intensive Case Management,
  • Clinical/medical supports
  • Community & social supports
  • Educational supports
  • Recreation
  • Caregiver & sibling supports
  • Equipment
  • Translation
  • Resource Counselling
  • Legal Assistance around system barriers


Typical patient ( ie. diagnoses, age, technology)

  • Having 1 or more chronic clinical condition(s), either diagnosed or unknown that are severe and/or associated with medical fragility
  • Having substantial family-identified health care service needs such as medical care, specialized therapy, and educational needs
  • Having high projected utilization of health resources that may include frequent or prolonged hospitalization, multiple surgeries, or the ongoing involvement of multiple sub-speciality services and providers 
  • Having functional limitations that are typically severe and may require assistance from technology such as a tracheostomy tube, feeding tube, or a wheelchair

Inclusion criteria

  • Technology dependent and/or use of high intensity care
  • Fragility, chronicity, complexity


Exclusion criteria


Team constituent or organizational structure

  • Physician
  • Nurse Practitioner
  • Social Worker
  • Dietician
  • OT, PT, SLP, PCVC, 
  • Ostomy nurse,
  • TPN nurse consulted as needed


Program funding


Program evaluation

CMC/family experience/satisfaction

Clinical research

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Created by Lisa Stromquist on 2015/09/03 21:52