Complex Continuing Care

Program description:

• 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-centred care and goals focusing on quality of life.

Goals of the program:

• Assessment, treatment and care for patients with multiple chronic complex medical conditions and diagnoses.

• Inclusion
  • 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

• Exclusion
  • Dialysis
  • 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.

Application Process:

• 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.