Established in 2012, the Complex Care Task Force is a multi-disciplinary team chaired by Dr. Ahmed Al Hammadi and co-chaired by Dr. Reem Babiker. Through collaboration between HMC and SickKids International, the task force aims to introduce a new model of care for patients with medically complex conditions. This program will not focus on a particular disease, but instead, will manage the consequences of multiple diseases. The initiative will define who falls into the category of complex care, what families need in order to cope, and how such services can best be provided.
The task force is working to implement various programs to ensure patient care remains consistent, comprehensive and oversees a smooth transition into community care, all the while empowering families with the knowledge and capability of taking care of a child with medically complex conditions. On the in-patient ward, the Complex Care Team provides continuity of care for the patient. Upon discharge, a nurse practitioner provides the caregivers with a written care plan highlighting the needs and sub-specialties they will need to keep in contact with. This care plan is an electronic and written document that functions as a ‘medical passport’ so information is shared between all healthcare practitioners involved. Community alliances will be developed to ensure families can access their services. As well, the task force envisions incorporating virtual outpatient care through the ‘virtual clinic’. This service provides accessibility to complex care team members outside a hospital setting. All these initiatives come together in the healthcare coordination plan that aims to foster collaboration and cooperation with healthcare providers in the hospital and within the community to ensure families are able to access quality healthcare at every turn. All these initiatives ensure the consistent dissemination of information, prevent crises, and reduce the need for hospitalization and emergency room visits.
Though our aspirations may seem far-reaching, the Complex Chronic Care Clinic was inaugurated on 2 October 2012. The clinic is based in HGH Outpatient Department to allow the immediate availability of medical subspecialties to consult as needed. A referral form has been developed and already in use by the Complex Chronic Care Team. The inclusion and exclusion criteria for the clinic have been discussed and agreed upon, and are based on review of referral and priority assessment. As well, SMEs from SickKids International facilitated a workshop that was attended by the HMC Complex Care Team. Among the topics discussed were clinic design and processes, role development and responsibilities, and clinic implementation. A clinical practicum was held at the Children’s Development Center to illustrate the themes discussed with the help of a pediatric patient with medically complex treatment and their family. In line with the workshop, the SMEs conducted a learning needs assessment towards establishing an educational and mentoring support plan, which formed the basis of an education plan with applicable learning opportunities to guide the professional development of new recruits.
The Complex Care Team has made great progress in developing a plan that promotes consistent, constant, child-focused and family-centered care. A lot remains to be achieved, but the team is dedicated, hard-working and determined to make a positive difference in the lives of these young patients and families.
