2010 Award Finalist

Complex Care through Community Partnerships – Integrated Model Project

Category - Improving Integration

The Problem

One of the realities facing healthy care systems today is that while steady advances in medical knowledge and technology have resulted in fewer people dying from disease, more and more people are living with them, and requiring care for them, as a result. This is as true for children as it is for adults. While mortality rates for children are on their way down, there has been a dramatic increase in the prevalence of children with complex, chronic health needs (CCCHN). Coordination of care for these children is extremely challenging, and there is a profound need to identify acceptable and sustainable solutions to meet their care requirements.

The Innovation

To meet that growing need, SickKids, the Toronto Community Care Access Centre and Holland-Bloorview Kids Rehabilitation Hospital engaged in a voluntary integration effort to develop an Integrated Complex Care Model that overcomes organizational boundaries. Targeted interventions include the assignment of ‘key workers’ as a single point of contact to help facilitate better care coordination, maximize accessibility, minimize duplication of services and resources and ultimately help improve health outcomes and enhance the health care experience for the child. In its first iteration in 2006, a hospital-based complex care ‘virtual’ clinic was developed and run collaboratively by a nurse practitioner and a paediatrician focusing on family-identified needs. 90% of communication with families occurred by telephone or email. In 2009, the project expanded to include broad Toronto Central LHIN representation: Toronto Central CCAC, Toronto East General, Holland-Bloorview Kids Rehab, SickKids, Community Pediatric Practitioners.

The Results

Both qualitative and quantitative evaluations of the project have shown that it has resulted in decreased hospitalizations, improved access to ambulatory resources, and overall cost savings for the children enrolled. From a health resource utilization perspective, preliminary evaluation of the integrated complex care clinic has demonstrated decreased utilization of inpatient resources, increased access to ambulatory resources, and substantial decreases in overall health care costs. In addition, families have reported seeing what was very poor health-related quality of life improve substantially after enrolment of the child in the clinic.

Next Steps

The results of the Complex Care through Community Partnerships project will be consolidated and used to inform and develop a business case and implementation plan that will be presented to the Toronto Central LHIN for consideration in adopting the model as a best practice in providing optimal care to children with complex and chronic care health needs.