Holland Bloorview Outpatient Clinics

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

Objective/Mandate/Goals

The Complex Care Neuromotor NP Clinic was established to increase access to care by relieving the follow-up waitlist for Developmental Pediatricians in the Neuromotor clinic by transitioning children with medical complexity and higher care needs to the NP clinic for ongoing follow up and case coordination.


Services/activities that help to meet the objectives

The Complex Neuromotor NP Clinic was established to increase access to care, improve client and family satisfaction, quality of care, improve health care utilization, provide timely follow up, increase communication between care providers, support case coordination, provide comprehensive care, health care system navigation and bridge gaps in current health services.  


Typical patient ( ie. diagnoses, age, technology)

Clients aged 2-15 years with a diagnosis of CP GMFCS IV & V, AND/OR have complicated genetic/metabolic condition currently followed by the Child Development Program with the Neuromotor Team


Inclusion criteria

Children who have:

  • unmet care coordination needs
  • multiple care providers
  • health care services delivered in more than one location – home, group home, school, hospital, clinic
  • care coordination challenges related to developmental disability or diagnosis that affect function or participation at school, home, recreation programs
  • challenges with primary care provider meeting care coordination needs

 OR

  • Require treatment, routine screening, health teaching and/or health promotion for comorbidities, or technological dependence
  • constipation, GERD
  • poor weight gain, nutritional support
  • acne, eczema
  • Scoliosis, hips subluxation, monitoring of tone, spasticity
  • assessment of development and functional status

OR

  • Have complex psychosocial circumstances.

Exclusion criteria

  • Clients currently followed by the Complex Care Team at Sick Kids, unless a case can be made that the client’s needs would be met by the NP Neuromotor clinic (discussion to occur between referring provider and NP)
  • Clients currently followed by the Integrated Complex Care Model (ICCM) Project (Sick Kids, CCAC, Holland Bloorview partnership pilot). These children may be transferred to the NP Neuromotor Clinic following the pilot, if the client fits the inclusion criteria.
  • Clients > 16 years of age
  • Clients who live outside of Toronto and fall into the catchment areas of Erin Oak, Grandview, Children’s Treatment Network, etc.
  • Clients who have not been seen by a developmental pediatrician at Holland Bloorview for >2years, unless the reason for lack of follow up is related to the complexity of the child and family.

Team constituent or organizational structure

Phase 1: Referral/transfers to Complex Care Neuromotor NP clinic are only available from Allied Health team members in the Child Development Program at Holland Bloorview.

Phase 2: New Clients and Referrals

All new referrals require an initial consultation by one of the Developmental Pediatricians either independently or in collaboration with the NP.

New clients whom meet inclusion criteria can be transferred for follow up in NP clinic after the initial consult if agreed upon by the NP and Physician collaboratively.

Phase 3: Patients are then transfered to the NP clinic and ongoing follow up is completed by the NP.  Physician consultation and collaboration with the with the original referring Developmental Physician is available on an as needed basis. 

Phase 4:  When care requirements no longer meet criteria for the Complex Care 

Program funding

Program funding comes through the Child and Development Program at Holland Bloorview. 


Program evaluation

  • Client satisfaction survey (CSQ-8) has shown that Primary “key workers” for case management in the care of CMC resulted in higher levels of family, client and interprofessional satisfaction as identified by Tessa Gressly-Jones evaluation of the Complex Care Neuromotor clinic.  


Clinical research

Bloorview Research Institute

  1.  Evaluation of Primary care worker for case management.  Finding to be published this year by Tessa Gressly-Jones
  2. Addressing Primary Care Service Gaps for transition aged youth with Cerebral Palsy. (initial phase: currently applying to REB 2015)
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Created by Lisa Stromquist on 2015/09/03 19:36