Integrated Outpatient Complex Care Program

The Integrated Complex Care Program is a specialized program aimed to improve and support the care of Children with Medical Complexity (CMC) who maintain connection to ACH subspecialties and are primarily cared for in the community and are not already attached to other tertiary complex care programs / services. The aim is to help children and families thrive in the community.

The Integrated Complex Care Program looks to connecting directly with the community and being able to provide support at the tertiary level. An important focus of this program is the team’s integration to the current team, with no expectation to assume care, to support community pediatricians caring for complex patients through improved communication and coordination between providers, services, and ministries, with the ultimate goal to create improved patterns of service delivery and utilization. In the context of significant medical complexity, some families have difficulty accessing healthcare services for their child due to unstable or unpredictable medical, psychosocial, sensory or engagement factors. The ICCP provides goal-oriented episodes of care to support families in accounting for the overall health or medical management, care coordination, and family support and resourcing activities.

Our services include:

• collaborative goal-setting
• care coordination across community and ACH
• care planning support
• link to other specialty resources
• support for transition between care settings
• information sharing with family, care providers, school, community, and others
• navigating between stakeholders, identifying needs, and next steps with families
• engage in community activities (e.g., FSCD, summer camps, AAFS, etc.)
• support family access and supports (e.g., transportation, housing, school)
• medical monitoring and information sharing