A partnership model for children with complex medical conditions: The Champlain Complex Care Programme in Canada How was it achieved and who was involved?The new model was strongly driven by the Chief Executive Officers of the founding partner organisations as well as the Champlain Local Health Integration Network (LHIN).The LHINs were created by the Ontario government in March 2006 as 14 not-for-profit corporations who work with local health providers and community members to determine the health service priorities of their regions of Ontario. While they do not directly provide services, their mandate is to plan, integrate and fund health care services and they oversee nearly two-thirds of the $37.9 billion health care budget in Ontario. The Children’s Hospital of Eastern Ontario (CHEO) acted as the lead organisation in developing the model. Over the past 40 years, CHEO has established itself as a world-class centre providing leading-edge treatment and compassionate care for children and youth from the age of 0 -18 years. The project was identified as a priority project by the CHEO Family Forum (a hospital advisory committee, consisting of parents). The CHEO's large service area includes not only Ottawa, but also Eastern Ontario, Western Quebec, Nunavut and parts of Northern Ontario but, due to the funding sources, the programme focuses services only the Champlain LHIN for the moment and therefore does not provide services to families in Quebec and Northern Ontario. The linkage to CHEO for specialized services, to CCAC, OCTC and CA for community-based services, and to the Champlain LHIN for oversight and guidance as the funding organisation, provides an organising structure that facilitates inclusion of primary care providers, a large proportion of whom are the paediatricians. This structure allows for easy integration, improved access and reduction of silos. The programme partners established a governance structure to ensure evidence-based decision making, including both a Steering Committee consisting of family members and senior executives from each partner organisation and an Advisory Committee consisting of family members and middle management from each partner organization, as well as a Programme Team that is CHEO-based and runs the day-to-day programme. The partners set up an inter-disciplinary programme team consisting of a project manager, several nurse coordinators and a Most Responsible Physician (MRP). the project manager and MRP were CHEO-based, the care coordinators were based in each partner organisation and were assigned to the patient and family based on an assessment of the unique care needs required and which partner organisation or combination of organisations could best meet those needs. Allied health care provider services (dietician, social workers, physio, etc.) were provided in kind by each organisation. Each of the partners in turn linked to other community providers, including respite care, service coordination, education, public health, palliative care etc. as depicted in the Care Coordination Model below.  33 patients and families were randomly selected to participate in a pilot after having met the programme’s defined ‘inclusion criteria’ which were:
Further details about the eligibility criteria can be found in the attached pdf. Family-Focused Meetings were conducted that included patients, families, specialists, multi-disciplinary medical teams and allied health providers to assess the unique needs of each patient and determine if their care team should be hospital or community-based or a combination of both. In general, patients in the programme were receiving services of 11 medical specialities, 93.8% required specialised medical equipment and all were considered medically fragile. The following diagram depicts the care and service providers involved with a “typical” child in the programme.  The pilot was evaluated in early 2013 with a view to scaling up the existing programme to serve more patients in the Champlain Region. In order to accomplish this objective the Care Coordination Model was maintained and the programme formalised its structure to include a Service Delivery Model with three levels of coordination to further meet the needs of a complex paediatric population and further integrate community and hospital providers. In this model the best care provider for a particular patient is determined by the patient condition and required interventions. Patients can move back and forth across the model based on their needs. The levels of care coordination are depicted in the following diagram:  Furthermore, the partnership proposed that the pilot project expand beyond the pilot to create the Champlain Complex Care Programme that would support a larger number of patients and extend to further community-based involvement. Such a programme would offer the following additional benefits:
A further enhancement was that Rapid Response Nurses were put in place in November 2013 to reduce re-hospitalization and avoidable emergency department visits by improving the quality of transition from acute care to home care. These nurses will visit the homes of children with complex needs within 24 hours of discharge to ensure that discharge instructions are understood, to contact the primary care provider, to arrange for a follow-up appointment within 7 days and to assure the medication arrangements. Research has demonstrated that these activities decrease the risk of readmission to acute care. |
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Dr. Nathalie Major-Cook, MD, FRCPC Email: nmajor@cheo.on.ca Elke Loeffler, CEO of Governance International wrote this case study on |
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