Complex Continuing Care

Program description:

• The Complex Continuing Care (CCC) 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

• 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.
• Our Interprofessional care team will determine whether a patient’s condition has stabilized and they no longer require CCC level of care. Cooperation and collaboration in discharge planning is expected as our care team supports and facilitates transition to the next appropriate care setting.

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. For fax referrals, please use the GTA Rehab Network Rehabilitative Care & CCC Referral Form. All applications are reviewed to confirm that our services appropriately meet the patient’s care needs.