SickKids Complex Care Program

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

Objective/Mandate/Goals

Provision of intensive case management, care coordination and specialized expertise for medically fragile and complex children and their families with goal to minimize hospitalizations and optimize quality of life.

Services/activities that help to meet the objectives

  • Regular clinic visits with complex care MD, NP and specialized team of interprofessional providers
  • Single point of contact for families (NP)
  • Development and maintenance of care plan that follows patient across all settings
  • CNS/MD inpatient consult team
  • Administrative coordinator to assist with system navigation and coordination of sub-specialty ambulatory services

Typical patient ( ie. diagnoses, age, technology)

Varies widely.   Accept new referrals up to age 16.

  • Technology dependent (eg. tracheostomy, G-tube etc.)
  • Patient with medical fragility and complexity (eg. neurodegenerative condition) requiring frequent hospitalizations and followed by multiple sub-speciality medical and interprofessional providers (eg. paediatrics, neurology, developmental paeds, metabolics, GI etc.) 
  • Children with  functional limitations, high resource utilization, variety of underlying diagnoses, variety of ages. 

Inclusion criteria

  • Medical complexity and fragility
  • Multiple subspecialty service involvement
  • Dependent on medical technologies
  • Frequent hospitalizations

Exclusion criteria

  • Care needs are met within existing well established subspeciaty program (eg. haem/onc, cardiology, respirology etc.)
  • Patient/Family do not feel that services offered through the complex care team are required or of benefit.
  • Over age 16

Team constituent or organizational structure

Team consists of MD and APNs as primary team members.  APN is key contact for families, key system navigator and care coordinator.  Allied health including social work, dietetics involved.  Each outpatient NP holds clinics at Sick Kids and a satellite community hospital, together with pediatricians in each location.  Inpatient complex care consultation team at Sick Kids as well, APN and MD providing care coordination and continuity of care for inpatients with medical complexity.

Program funding

Combination of base hospital funds, one-time revenue streams (P4R incentive funding) and cost-recoveries for portions of NP FTE contracted to satellite hospitals.

Program evaluation

Dr. Cohen has published several formal program evaluations.  In addition, we track metrics related to LOS, ED visits and frequency of hospitalizations, patient and provider satisfaction (periodic).

Clinical research

Our team is engaged in a number of research projects.  Please contact me for further information.

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Created by Lisa Stromquist on 2015/09/03 22:30