Complex Care

As a program of excellence, the Complex Care Service at the Montreal Children’s Hospital works to promote a continuum of care for children and youth with complex medical conditions that is family-centered, safe and personalized, ideally in their home environment.

Our program aims to improve the quality of life for these children by :

• Preserving and promoting the independence of the child and family
• Minimizing the negative consequences of intensive home care for the child and family
• Promoting each child’s growth and development
• Reducing unplanned hospitalizations and emergency room visits
• Effectively coordinating child and family needs with hospital, community and home-based services

Services

• Designated nurse and primary pediatrician for longitudinal care
• Discharge planning and coordination
• Central point of access to care
• Nurse/physician on-call service
• Multi-disciplinary clinic visits
• Daily urgent care visits through Complex Care Service clinic.
• Care plan including acute care management
• Care coordination / Liaison with community providers

Referrals

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, send the following documents to us by fax to 514-412-4424. Please include:

• Consultation form indicating the reason for referral
• Medical summary, if possible

Community referrals will be carefully evaluated and prioritized accordingly. Upon receiving a consultation request, we will send an acknowledgment letter to the referring community physician. This letter will include either a scheduled appointment date or an estimated wait time for the patient to be seen at our Consult Clinic. Following the patient consultation, we will update the referring community physician regarding the patient’s eligibility for admission into our complex care service. If the patient does not qualify for our program, we will provide the referring physician with a detailed explanation of the reasons.

Programs

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

• Home total parenteral nutrition (IV nutrition)
• Bronchopulmonary dysplasia (BPD) home oxygen program
• Neuromuscular disorders
• Tracheostomy and home ventilation (breathing machines)
• Long-term intravenous (IV) therapy
• Congenital Hemostasis Program
• Post cardiac transplant
• A “multiplex” program for children with more unspecified complex health care needs
• Satellite enteral nutrition program

Team