Complex Care

The Complex Care program is part of the Division of General Pediatrics at BC Children’s Hospital.

About

Vision & Philosophy

The Complex Care program strives to ensure continuity and coordinated health care to children and youth with medical complexity (CYMC). The team aims to support families to access services and supports which improve health, well-being and quality of life.

Who is followed by the Complex Care Program?

The children and youth followed by Complex Care are those who demonstrate the most complex, chronic medical care needs.
Our expertise is caring for children with genetic syndromes and neurologic impairment who have multiple subspecialists involved in their care each year, frequent hospitalizations, multiple medications and high intensity care needs, often dependent on technology.
Our expertise is not caring for children with cancer, transplant, psychiatric and behavioural challenges.
We accept referrals from physicians or nurse practitioners.

Who are the members of the Complex Care Program?

We have 1 part-time pediatric nurse practitioner and 3 part-time pediatricians who have expertise and interest in complex care and/or palliative care. We provide Monday-Friday inpatient consults and week-day outpatient care. We also have two part-time booking clerks who provide appointment coordination.

Booking (appointment coordination) support

Kathleen (Regina) DeGuzman

Clerical support

Harleen Gill

Medical Team

Gabrielle Bibas, Pediatrician

Tessa Diaczun, Nurse Practitioner

Elizabeth Grant, Pediatrician

Esther Lee, Pediatrician

We are part of a teaching facility for University of British Columbia and may have trainees working with us (e.g. medical students, pediatric residents and fellows).

Referral

You need a referral from a doctor or a nurse practitioner to use this clinic.

Services

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.

First outpatient visit

Your first outpatient visit

Families are sent a welcome package after their appointment is confirmed; packages include forms that must be filled in prior to the appointment. The initial visit can take up to two hours and families must arrive 15 minutes before their appointment. Teaching and counseling will be provided according to the child's and family’s needs. Reports will be sent to the family as well as health care professionals involved in the child’s care.

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