Complex Continuing Care
- The Complex Continuing Care program focuses on providing assessment, treatment and care for patients with multiple chronic complex medical conditions and diagnoses.
- The interdisciplinary team supports and optimizes patient-centered care and goals focusing on quality of life.
- A chronic care co-payment fee may be applicable, per the Ontario Ministry of Health and Long Term Care guidelines. With appropriate financial documentation, a reduced co-payment may apply depending on the patient’s income. This will be determined by the Finance Department upon admission.
Goals of the program:
- Assessment, treatment and care for patients with multiple chronic complex medical conditions and diagnoses.
- Adults age 60 and older
- Patient is medically stable (i.e. does not require acute care intervention)
- If patient smokes, is able to do so safely and make own arrangements
- Chronic complex illness with multiple co-morbidities that require ongoing medical intervention
- The program is able to manage the following needs:
- Patients with compromised skin integrity > Stage Two
- Patients with tracheostomy
- Patients with peripherally inserted central catheter (PICC) lines
- Enteral feeding tube (G/J –tube)
- Nephrostomy and other drains
- Should a patient’s condition stabilize and this level of care is no longer required, cooperation on discharge planning to the appropriate setting is expected
- Mechanical ventilation
- Bi-level Positive Airway Pressure (BiPAP)
- Cuffed Tracheostomy Tube
- Needs greater than 50% Oxygen
- Total parenteral nutrition (TPN)
- Bariatric equipment needs (300lbs +)
- Patient’s needs can be reasonably met in a community or Long Term Care setting
- Patients with Stage 1 and Stage 2 ulcers without complex medical needs
- Patients with a gastrostomy tube (G-tube) or well established tracheostomy without complex medical needs
- Patients requiring a locked/secure unit
- Patient requires extensive rehabilitation or physiotherapy
- Patients with responsive behaviours will be assessed on a case by case basis
Expected Length of Stay:
- Length of stay will vary by individual needs, determined by the health care team.
- An application can be sent by the patient’s health care team in acute care through the Resource Matching and Referral (RMR) system or via fax: 416-785-2471
If you have questions, please contact:
- For more information, you may contact a social worker at 416-785-2500, ext. 2325.
Click to print or download the brochure for the Complex Continuing Care Program.