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

Objectives

In 2009 a partnership was formed with the objectives of improving coordination of care and reducing preventable hospital admissions by a group of organisations, including Champlain Community Care Access Centre (CCAC), Ottawa Children’s Treatment Centre (OCTC), the Children’s Hospital of Eastern Ontario (CHEO), Ottawa Children's Coordinated Access & Referral to Services (Coordinated Access) with oversight by the Champlain Local Health Integration Network (LHIN).

The goals of the Champlain Complex Care Programme were

• to provide a family-centered approach for technology-dependent, medically complex and fragile children and youth;
• to facilitate communication and collaboration among care providers;
• to coordinate needs across the system; and
• to relieve the burden on families of navigating the system alone, in order to aid in the overall objective of improving health status for those impacted.

A successful partnership approach was expected to improve the health of these children and young people and their families by supporting them to live at home, go to school, spend time with friends and participate in leisure and community activities with family and peers; while, at the same time, standardising the processes and identifying efficiencies in the overtaxed system upon which they relied for their continuing care needs.

Subsequently, programme partners agreed to scale up the partnership model after a three-year pilot phase from 2009-2012, so that it would be able to serve a greater number of the approximately 500 children and young people who account for about 50% of the total ‘paediatric-weighted’ cases of this age group in the region.