Intermediate-Complexity Coordination and Navigation (I-CCAN) Service

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The I-CCAN team, composed of care coordinators, nurse practitioners, nurse clinicians and pediatricians, endorses strategies such as family-centred proactive care planning and interdisciplinary collaborations to transform care delivery for children with medical complexity.

Care Coordinators:

• Laura Gagnon, M.S.W.
• Kaitlen Gattuso, B.Sc., CCLS

Nurse Practitioner:

• Laurie Cleophat, PNP, MSc(A)

Pediatricians:

• Sara Long-Gagné, MD
• Matthew Donlan, MD

Service Directors:

• Sara Long-Gagné, MD
• Isabelle St-Sauveur, RN, MSc(N)
• Nadia Eldaoud, RN, M.Sc (Mgmt)
• Hema Patel, MD

Service Development Consultants:

• Loredana Martello, Care coordinator/Administrative Agent
• Lise Gagnon, M.Ed., CCLS
• Marie-Claude Proulx, RN, MSc(A)

The Phase 1 of I-CCAN was launched in August 2020! In Phase 1, eligible families were appointed to a care coordinator, nicknamed super-schedulers, offering concierge-like services. The care coordinators are non-medical care workers with experience navigating the MCH services. The main role of the care coordinator is to assist families to centralize and simplify scheduling of outpatient MCH services. With the success of Phase 1, in January 2022 the I-CCAN service is already expanding to Phase 2. In Phase 2, the I-CCAN service will also be offering medical care consultations and nurse practitioner/clinician-led integrated care to the subset of patients with the most complex care needs.

Each child and youth will be assigned a care coordinator who will serve as a point of contact to assist the family in coordinating, consolidating and simplifying hospital visits. The care coordinator will organize and coordinate MCH medical visits and/or imaging/tests and/or therapies/procedures according to the family unit’s availabilities and preferences.

Medical care consultations by our pediatricians (+/-nurse practitioner) via the I-CCAN clinic, as well as the support of a nurse practitioner/clinician, may be offered to the most complex subset of I-CCAN patients that may benefit from integrated care services. I-CCAN services offered to families will be determined at the initial needs assessment following enrollment to the I-CCAN service and may be reassessed according to the evolution of the patient/family needs.

In summary, the I-CCAN service is meant to help:

1. Prioritize care delivery based on expressed needs

2. Harmonize the care offered by various services at the Montreal Children’s Hospital

3. Reduce the time dedicated to organizing hospital visits and decrease unnecessary travels to the hospital—for example, when possible, plan for multiple medical appointments/tests on the same day

4. Reduce delays in accessing needed care

Children and youth followed by 3 or more MCH service providers (pediatricians, specialists, therapists, or other allied health professionals) for a period of at least 12 months and requiring support navigating outpatient MCH medical services. The family unit must also consent to enrollment with the I-CCAN service.

Children and youth followed by MCH service providers already providing coordination of outpatient medical visits will not be eligible for this service.

• If you are a parent or caregiver, please complete the following form.
• If you are a health professional, please complete the following form.

Please submit your completed document by fax (514) 412-4424 or email [email protected].

I-CCAN will contact eligible families for enrollment within 6-8 weeks of receipt of the referral. If the family accepts enrollment, a phone appointment will be scheduled with the I-CCAN care coordinator for a needs assessment.

The I-CCAN team will determine the patient’s care coordination needs and begin planning upcoming visits based on the family unit’s availabilities and preferences. The I-CCAN team will also exchange contact details with the family and service as the initial point of contact for coordination of outpatient medical visits. The family may still receive phone calls from the designated services for appointment booking. We encourage families to take those appointments to avoid delays in care but to keep I-CCAN in the loop to coordinate with other appointments if possible.

Medical care consultations (+/- NP services) may be offered to the most complex subset of I-CCAN patients that may benefit from integrated services. The latter will be determined following the needs assessment. I-CCAN does not provide an “oncall” service on evenings and weekends.

I-CCAN services are available during weekday hours (Monday to Friday, 8:30am to 4:30pm).