A partnership model for children with complex medical conditions: The Champlain Complex Care Programme in Canada

Learning points

Our programme has made the transition and is an example of the “ideal reformed system” defined in the report of the Commission on the Reform of Ontario’s Public Services, chaired by Don Drummond on behalf of the Ontario provincial government.

The partnership is governed by a Steering Committee consisting of the CEOs of all its component organisations, as well as family and physician representatives. The partnership is supported by an Advisory Committee and Programme Team. Annual renewal of Partnership Agreements keeps key issues to the forefront and provides an opportunity for each partner to report their proposed financial and in-kind services for the upcoming year. All members of the partnership exhibit a willingness to collaborate in order better and more quickly to coordinate health care services for children and young people with complex conditions.

This programme is a model that can be replicated in other communities or settings with the following characteristics:

• Patient-centric and family-centred care.
• Driven by co-ordination and navigation of services across providers (hospital, community, education) by inter-professional Patient Focused Teams.
• Focused on complex chronic care of the small population of children and young people with technology- dependent and medically complex cases, which use the most resources.
• Data collection, sharing and comparison between all providers.
• Dedicated to reduced healthcare spending, by demonstrating rigorously the scope for diverting care out of hospital and into the community.
• Quality assurance and supervision of the impact of the model of care on the system.

It is anticipated that the model may be generalised to other groups of children and young people with high use of health care, including all children with medically complex cases and ultimately all children with complex cases of any kind, who would benefit from similar models and tools (e.g. children and young people with mental health issues).

The partnership additionally has the capability to provide tools and resources and assume a lead role in successful transition of young people to the adult hospital system.