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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.
Click to print or download the brochure for the Complex Continuing Care Program.