What does the Complex Care Team add?

• Collaborative care: If the patient is not already connected to a local pediatrician and family physician, we will support them to find one. We will work collaboratively with the local pediatrician and/or primary care provider to ensure access to necessary care in a location that works for their family. We aim to build capacity within families and community providers with the goal of eventual discharge from the complex care program. 
• Continuity: We provide consultative care if the patient is admitted to BCCH, with the goal of providing continuity of care, in addition to care on an outpatient basis. We will support the family across transitions from inpatient BCCH hospital to home and home to BCCH. Outside of BCCH, we aim to ensure seamless transitions by helping the family to navigate systems and supporting local health care providers to care for the patient.
• Care plan: We provide routine comprehensive "big picture" reviews of the patient's medical and developmental needs in order to: update a written care plan; prevent errors at times of transition; provide access to services; provide preventative health and anticipatory guidance; provide family support.
• Coordination of appointments: We will help to organize tests, procedures and follow up visits at BC children's hospital in order to minimize travel to and from BCCH.
• Care coordination: We work to coordinate care between subspecialists and community providers. We aim to improve communication between providers.
  
• Shared decision making: We can help families make informed decisions about plans of treatment or care for their child for both the short and long term.
• Goal setting: We partner with families and caregivers to ensure that care is consistent with the child/youth and family needs, preferences and goals.
  

Discharge principles

• Through collaborative care, we aim to build capacity within families and community providers with the goal of eventual discharge from the complex care program. 
• The complex care team does not follow families indefinitely. As fragility/instability decreases or as family capacity increases, the team will explore discharge with the family.
• Triggers to consider discharge: No major changes in 12 months and/or no major hospitalizations in 12 months.
  

Preparing for your appointment at BCCH

Support for families with children with health complexity