Complex Care Service

Drs. Manon Allard, Catherine Millar, Catherine Henin, Anne-Marie Sbrocchi and Hema Patel.

Our Administrative professionals: Natalie Ross, Karen Wightman, Daphnay Mondelus,  Nancy Di iorio, and Rosanna Barrafato. 

Our Allied Health professionals: Anna Lachance, Judith Le Gallais, Chantal Champoux,  Vanessa Blagrave, and Marion Hahn.

Nathalie Aubin, Assistant Head Nurse, Nadia Eldaoud, Clinical Manager and Isabelle St-Sauveur, Clinical Nurse Specialist. 

Nursing team, top row: Annabelle Giroux, Annie Chaput, Sylvie Canizares, Isabelle St-Sauveur, and Eloisa Binder. Bottom row: Tania Lafleche, Nadia Eldaoud, Geraldine Schaack, Catherine Sabourin, Clelia Coccia, and Nathalie Aubin.

The Complex Care Service at the Montreal Children’s Hospital helps many patients and families who are dealing with a variety of complex medical conditions that require short-, medium- or long term care coordination. 

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Who we are

Caring for a child with special medical needs is challenging. These challenges are even greater when diverse medical conditions require many appointments with countless specialists, and when a child is prone to repeated illnesses and infections.

The Complex Care Service at the Montreal Children’s Hospital helps many patients and families who are dealing with a variety of complex medical conditions that require short-, medium- or long term care coordination. Our diverse team of health professionals works together to ensure a quicker, smoother transition from hospital to home, and provide the necessary support to allow a child with complex medical needs to remain at home.

 

The concept of the “medical home”

Keeping up with multiple doctors' appointments, tests, medications and medical equipment can be overwhelming. We therefore provide a “medical home” for children with complex medical needs and their families. The medical home does not refer to a physical location; rather it is a philosophy of ideal care that is:

  • Accessible
  • Compassionate
  • Continuous
  • Comprehensive
  • Coordinated
  • Culturally effective
  • Family centred

 

Our mission

The mission of the Complex Care Service is to provide safe, effective and family-centred care to children with complex medical needs, on a short-, medium- or long-term basis in the child’s own home environment.

We believe that caregivers and patients should participate in the health care assessment process, in implementation of therapy, and in preventive efforts whenever possible.

What kind of support do we provide?

Our service aims to improve the quality of life for children with complex medical conditions by:

  • Maintaining and encouraging child/family independence;
  • Minimizing the impact of intensive home care on the child and family;
  • Encouraging the growth and development of every child;
  • Reducing unscheduled hospitalizations and emergency visits;
  • Effectively coordinating the needs of the child and family with home, community and hospital services.

 

Our history

More than 45 years ago, a small forward-thinking group of healthcare professionals based at the Montreal Children’s Hospital (MCH) observed what seems obvious today:

  • That prolonged hospitalizations were detrimental to children in many ways,
  • That parents and caregivers were willing and capable of caring for their children with complex needs in their own homes,
  • That comprehensive and coordinated healthcare was essential for these special children.

Home-based care is identified as a need

In 1964, the Intensive Ambulatory Care Service (IACS) or “Homecare” service, as it was then referred to, started to transition children from hospital to home-based care and an era of innovation began. Children with intensive care needs associated with rheumatological, neuromuscular and hematological disorders were amongst the first served by the program. Through teaching and hands-on practice, parents learned how to look after their child’s needs at home. Community services were sparse; outreach education became an important team objective.

Intensive Ambulatory Care Service (IACS) to Complex Care Service

Subsequently, community services slowly grew and advances in technology allowed for increased home-based care. The “Homecare” service was renamed the Intensive Ambulatory Care Service (IACS) in the early 1990s and developed into the “medical home” that it is today, offering multidisciplinary coordinated care for children with a wide variety of special needs. In 2012, we again revised and refocused the clinical service to more closely fit the needs of our patients and families. The clinical service was renamed the Complex Care Service.

 

Our team

The Complex Care Service is a diverse team of health professionals who work together to coordinate the care of your child. We have a department head, a clinical manager, a number of dedicated physicians, an assistant head nurse, a clinical nurse specialist, nurse clinicians, a nursing assistant, a physiotherapist, an occupational therapist, a child life specialist, a social worker, a psychologist, a dietician, a patient care attendant and administrative assistants whose expertise is essential in ensuring that the diverse needs of complex care patients are met.

Our team members are dedicated to excellence and always strive to deliver the highest quality of care to patients. Over the years, the Complex Care Service has received numerous awards, special honours and recognition for excellence in the care of children, youth and families.

As a program, in 2006, the Intensive Ambulatory Care Service (as Complex Care Service was then called) won the inaugural Rotman Award for Paediatric Home Care Innovation, an award given by the Sick Kids Foundation National Grants Program. This award recognizes successful and innovative home and community programs for children and their families in Canada. The Rotman Award promoted the Intensive Ambulatory Care Service as a model of best practice from which other pediatric institutions could learn. Over the years, many pediatric hospitals across Canada have consulted with the Complex Care Service to learn about our program and to create a similar program in their own institutions.

Individual members of the Complex Care team have also been recognized for their dedication to providing quality health care to children with complex medical needs, ranging from nursing awards of excellence in leadership and clinical practice, research grants, and faculty appointments at the McGill University Faculty of Medicine and Faculty Lecturer, part time at the Ingram School of Nursing, to the 2012 Canadian Paediatric Society Victor Marchessault Advocacy Award for “outstanding contributions to making life better for children and youth at the local, provincial, or national level”, given to Dr. Hema Patel.

Staff members

 

Where the care happens

The Complex Care Service is part of the Pediatric Day Center and is located on the first floor (RC) of the B Bloc in room 2238.

We are open  Monday to Friday from 8:00 a.m. to 4:00 p.m.

 

Programs and services

If your child’s medical condition requires consultative or long-term care, their healthcare team may decide to refer you to our department. We have specific programs based on a child’s primary diagnosis, and some of our services include:

  • Assigned nurse case manager and physician
  • Regular scheduled clinic reassessments
  • Same-day urgent care appointments
  • A 24/7 on-call care service
  • Specialist care coordination
  • Home visits on admission to program
  • School liaison
  • Rehabilitation care liaison
  • CLSC liaison

Each program has a designated nuse case manager who oversees each child’s care and becomes the link between the family and the hospital. Each program also has a designated primary physician, although the team of physicians works together and gets to know all of the children in our service. In addition, each child is evaluated and followed as needed by a psychologist, a Child Life specialist, a physiotherapist, an occupational therapist, a dietician and a social worker.

In the last three years, we have seen an increase in the number of children being followed by our service. With improvements in the delivery of healthcare, more and more children with complicated care needs will be able to make the transition from hospital to home. In the coming years, we anticipate a steady growth in the number of patients we will follow in our service.

 

Conditions and illnesses

The Complex Care Service helps children and families who are dealing with any number of a wide range of medical conditions. Children within our programs typically have multiple care needs and may be vulnerable to sudden changes in their health. Many of our patients depend on equipment and technology such as feeding pumps, intravenous tubes for nutrition, suction machines, supplemental oxygen, tracheostomies and ventilators.

Our patients are separated into the following 10 programs, based on their primary diagnosis:

  • Cardiac transplantation
  • Home total parenteral nutrition (IV nutrition)
  • Bronchopulmonary dysplasia or BPD (chronic lung disorder)
  • Neuromuscular disorders
  • Immune deficiency (inability to fight off infections)
  • Tracheostomy and home ventilation (breathing machines)
  • Long-term intravenous (IV) therapy
  • Thalassemia (blood disorder)
  • Coagulation disorders
  • A “multiplex” program for children with more general complex health care needs.

Depending on the child’s medical situation, we may provide blood tests, intravenous medications, blood transfusions, as well as teaching family members to care for indwelling devices such as central venous catheters, tracheostomies and gastrostomy tubes.

 

Support for families

When the normal progression of a child's growth and development is disrupted by a medical condition or crisis, everyday life may become very challenging for the family. Our social services department has a very comprehensive list of references, resources and support services for families who are dealing with the complex medical needs of a child. This database can help you find more information on how to access government forms, learn more about support groups and community resources, and other useful information.

 

How to refer a patient

Children and teenagers with complex medical needs are considered for evaluation and follow-up in our service if the care that they require can be provided safely outside of the hospital and if a reliable caregiver can be identified. There is no minimum age requirement.

Geographically, services are focused on those patients living within the area of the McGill Réseau universitaire intégré de santé (RUIS), which includes the Abitibi region, Outaouais, Montreal, Montérégie, Nunavik, the Cree Territories and the James Bay region.

We occasionally care for patients from outside these areas in the cases of rare complex pediatric conditions. For example, we follow children throughout Quebec who require diaphragmatic pacing, home total parenteral nutrition, cardiac transplantation and tracheostomy care. With the collaboration of local services, including CLSCs and traveling clinics, we have been able to meet the needs of children living throughout the province.

We invite referring physicians and healthcare professionals who wish to refer a patient to our service to consult the following referral guidelines. Please note that a referral to Complex Care Service does not guarantee automatic acceptance into the program.

Referral guidelines

Children and adolescents may be referred to the Complex Care Service from within the hospital by a member of the patient’s healthcare team or by a physician in the community.

To refer a patient to our service, we ask that you send a:

  • Consultation form indicating the reason of referral
  • Completed “Physician Referral Form” (available upon request)
  • Medical summary, if possible

These forms must be sent by fax to 514-412-4424. Upon receipt of these documents, we will contact the family to complete the “Family Referral Form” for additional information. Once all documents are received, patients will be assigned a priority according to the needs identified. We then send a letter to the referring physician with either an appointment date, an estimated wait time for the patient to be seen in our Consult Clinic or an explanation of why the patient is not suitable for assessment in our program.

 

Conditions and illnesses

Refer a patient 
  • Room B.RC. 2238
  • To reach the office : 514-412-4420
  • To make an appointment : 514-412-4420 
  • Fax : 514-412-4424