The aim of the Complex Care Program is to provide responsive, integrated care for children with medical complexity. The Complex Care Clinic is offered to facilitate, not disrupt, care provided by IWK subspecialty services, and equally import, is ideally offered in supportive collaboration with, not in replacement of, the child’s family physician and/or community pediatrician. Eligible children are typically medically fragile, receive care by multiple subspecialists and allied health care workers, and require the support of medical technologies (such as feeding tubes). Our children and families are supported on weekdays by a Registered Nurse, who can serve as a first point of contact for IWK services, facilitate coordinated appointment when possible, and help trouble-shoot the unique challenges that arise in the care of children with medical complexity. The Complex Care Nurse Coordinator helps streamline communication, generally calling the week prior to appointments to gather and document the ever-changing health care needs and concerns. At the appointment, the child is typically assessed by the nurse coordinator, one of the Complex Care team’s four pediatricians, a dietician, a social worker and, if indicated, by other health care providers. These coordinated visits require a longer than typical appointment time and families are encouraged to plan appropriately for the extended visit.
The Complex Care Program consists of the following team members:
Dr. Joanna Holland
Dr. Stacie Colwell
Dr. Lauren Hanes
Penny Church, Social Worker
Debbie Balsor, Nurse Coordinator
Sheri Rose, Dietician
Katie-Lynn Balsor, Administrative Assistant
Accessing this Clinic, Program or Service
Criteria for Complex Care Program: (all criteria must be met)
- The patient must be less than 16 years of age.
- The patient must be followed by at least five PHYSICIAN sub-specialists.
- Must check one or more box in EACH of the four sections below to meet Medical Complexity (as defined by Provincial Council for Maternal and Child Health & Complex Care Kids Ontario, 2015):
- Technology Dependent and/or users of high intensity care:
- Child is dependent at least part of each day on mechanical ventilators, and/or child requires prolonged intravenous administration of nutritional substances or drugs and/or child is expected to have prolonged dependence on other device-based support (for example: tracheostomy tube care/artificial airway, suctioning, oxygen support, or tube feeding), and/or
- Child has prolonged dependence on any other medical devices to compensate for vital bodily functions, and requires daily or near daily nursing care (for example: cardiorespiratory monitors, renal dialysis due to kidney failure, urinary catheters or colostomy bags plus substantial nursing care), and/or
- Child is not technologically dependent but has any chronic condition that requires as great a level of care as the above group, such as:
- Children who, as a consequence of their illness, are completely physically dependent on others for activities of daily living at an age when they would not otherwise be so dependent,
- Children who require constant medical or nursing (or delegate with competency) supervision or monitoring resulting from the complexity of their condition and/or the complexity of medication administration and/or the quantity of medication and therapy they receive.
- Fragility:
- The child has severe and/or life-threatening condition, lack of availability and/or failure of equipment/technology or treatment places the child at immediate risk resulting in a negative health outcome, and/or
- Short-term changes in the child's health status (illness) put them at immediate serious health risk, and/or
- As a consequence of the child's illness, the child remains at significant risk of unpredictable life-threatening deterioration, necessitating round-the-clock monitoring by a knowledgeable caregiver, and/or likely to experience exacerbation of chronic condition necessitating assessment by a healthcare provider in a timely manner.
- Chronicity:
- The child's condition is expected to last at least six more months, or
- The child's life expectancy is less than six months.
- Complexity:
- Involvement of at least five healthcare practitioners/teams and healthcare services are delivered in at least three of the following locations:
- Home
- School/ Nursing school
- Hospital
- Community-based clinic (e.g., doctor's office)
- Other (at clinician's discretion)
- The family circumstances impede their ability to provide day-to-day care or decision making for a child with medical complexity (for example, the primary caregiver and/or the primary income source are at risk of not being able to complete their day-to-day responsibilities).
Additional Considerations:
Patient is a newborn or has received a new diagnosis; while they currently do not meet criteria, consistent with their diagnosis/condition, it is strongly predicted that they will meet full Complex Care criteria within the next calendar year.