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Community Complex Care Program   at
Alberta Children's Hospital
Specialty: Pediatrics
Connect Care Department: CGY ACH COMPLEX CARE SRVCS
Estimated time to routine appointment: Within 9 months
Alberta Health Services - Calgary Zone
SERVICE DESCRIPTION
The Community & Outpatient (COMM-CCP) stream of the ACH 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 receiving other complex care services. The aim is to help children and families thrive in the community.Community Complex Care Program is a stream that provides comprehensive support for patients who receive care in the hospital, community, or at home. The COMM-CCP team is composed of care coordinators and family resources specialists, who help patients and families with accessing and navigating the health care system and the resources and services they need. The service includes pediatric care coordination, which is a patient and family-centered, assessment driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families and care teams. The COMM-CCP partners, alongside the referring care team, to coordinate care and addresses interrelated medical, social, developmental, educational, and financial needs to achieve optimal health and wellness outcomes for patients and families.

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
  • explore community activities
  • improve family access and supports
  • medical monitoring and information sharing
The team does not assume a primary care / therapy team role. COMM-CCP requires active participation from the patient’s care team(s) (e.g., social work, physician, family, school team).
The Community & Outpatient (COMM-CCP) stream of the ACH 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 receiving other complex care services. The aim is to help children and families thrive in the community.Community Complex Care Program is a stream that provides comprehensive support for patients who receive care in the hospital, community, or at home. The COMM-CCP team is composed of care coordinators and family resources specialists, who help patients and families with accessing and navigating the health care system and the resources and services they need. The service includes pediatric care coordination, which is a patient and family-centered, assessment driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families and care teams. The COMM-CCP partners, alongside the referring care team, to coordinate care and addresses interrelated medical, social, developmental, educational, and financial needs to achieve optimal health and wellness outcomes for patients and families.

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
  • explore community activities
  • improve family access and supports
  • medical monitoring and information sharing
The team does not assume a primary care / therapy team role. COMM-CCP requires active participation from the patient’s care team(s) (e.g., social work, physician, family, school team).
ELIGIBILITY REQUIREMENTS
Ensure that family and team are aware of and consenting to a referral to this program. Referrals accepted from Community physicians, ACH subspecialists, and ACH clinics. Primary team and/or provider MUST remain involved in care; this is a consultative/supportive service. 
Child/Youth must include all of the following: 
  • Biomedical Complexity (chronic, multisystem co-morbidities)
  • Functional Limitation (multiple medical conditions accompanied by significant functional and/or adaptive impairment)
  • High Health Care Utilization across an ACH clinic(s) or program(s) (high service/resource utilization and service needs spanning multiple subspecialties and government ministries)
  • Patient and caregiver need (high intensity direct care requirements and associated impact on family functioning [e.g., financial, demands on time, appointments, and unmet care needs] and psychosocial/systemic complexity factors may be present
  • Who require support beyond the standard level, which cannot be provided by specialized or community resources, and which negatively affects the medical, social, developmental, educational, and financial need of the patient and their family
Child/Youth Exclusion
  • 18 years and older
  • Being referred for acute medical and mental health crisis emergency
Ensure that family and team are aware of and consenting to a referral to this program. Referrals accepted from Community physicians, ACH subspecialists, and ACH clinics. Primary team and/or provider MUST remain involved in care; this is a consultative/supportive service. 
Child/Youth must include all of the following: 
  • Biomedical Complexity (chronic, multisystem co-morbidities)
  • Functional Limitation (multiple medical conditions accompanied by significant functional and/or adaptive impairment)
  • High Health Care Utilization across an ACH clinic(s) or program(s) (high service/resource utilization and service needs spanning multiple subspecialties and government ministries)
  • Patient and caregiver need (high intensity direct care requirements and associated impact on family functioning [e.g., financial, demands on time, appointments, and unmet care needs] and psychosocial/systemic complexity factors may be present
  • Who require support beyond the standard level, which cannot be provided by specialized or community resources, and which negatively affects the medical, social, developmental, educational, and financial need of the patient and their family
Child/Youth Exclusion
  • 18 years and older
  • Being referred for acute medical and mental health crisis emergency
Referral instructions for primary care, community care, private
providers etc. who do not send referrals via Connect Care.
REFERRAL PROCESS - FOR NON-CONNECT CARE USERS
Please review eligibility requirements and referral guidelines before making a referral to this service. 
Complete the referral form and fax it to the service using the contact information in this profile.
Please review eligibility requirements and referral guidelines before making a referral to this service. 
Complete the referral form and fax it to the service using the contact information in this profile.
REFERRAL PROCESS - FOR CONNECT CARE USERS
Please review eligibility requirements and referral guidelines before making a referral to this service. 
Send an Internal Referral using the Ambulatory Referral Order to Pediatrics, type CGY ACH COMPLEX CARE SRVCS in the “To Department” section and complete order using [COMMCCPREFERRAL] SmartPhrase in comments. The SmartPhrase is searchable in SmartPhrases Lookup, where you will +Add Me under Sharing.
Please review eligibility requirements and referral guidelines before making a referral to this service. 
Send an Internal Referral using the Ambulatory Referral Order to Pediatrics, type CGY ACH COMPLEX CARE SRVCS in the “To Department” section and complete order using [COMMCCPREFERRAL] SmartPhrase in comments. The SmartPhrase is searchable in SmartPhrases Lookup, where you will +Add Me under Sharing.
ADDITIONAL SERVICE DETAILS
All referrals submitted will be reviewed by our team and directed into one of two service streams based on the information provided:
  • Consults: This stream involves provider-to-provider support. Our team will review the referral to connect with other healthcare providers and share information on potential solutions or resources. This may include facilitating connections between care providers.
  • Active Care Coordination: In this stream, our team works collaboratively with the patient, their family, and care teams to understand the patient's needs. We offer comprehensive support and coordination across various areas of care.
The details provided in the referral will guide the team in determining the appropriate service stream.
All referrals submitted will be reviewed by our team and directed into one of two service streams based on the information provided:
  • Consults: This stream involves provider-to-provider support. Our team will review the referral to connect with other healthcare providers and share information on potential solutions or resources. This may include facilitating connections between care providers.
  • Active Care Coordination: In this stream, our team works collaboratively with the patient, their family, and care teams to understand the patient's needs. We offer comprehensive support and coordination across various areas of care.
The details provided in the referral will guide the team in determining the appropriate service stream.
COMMUNICATION PROCESS
  • Referral receipt to referring source within 7 days.
  • Acceptance via appointment details or wait list status letter to referring source and patient within 14 days.
  • Wait list status update every 90 days.
  • Appointment outcome to referral source within 30 days.
 
PHONE
403-955-7281
FAX
403-668-2150
REFERRAL PHONE
403-955-7281
REFERRAL FAX
403-668-2150
REFERRAL FORM
LINKED SPECIALISTS
CLICK + TO VIEW REFERRAL GUIDELINES
+-
Routine Reason for Referral
Access Targets convey the clinically appropriate timeframe patients should be seen within, by reason for referral and priority level.
Access Target
Required Information/Investigations
Investigation Timing
Additional Details
+-
Complex care needs
Medication List (dose, frequency, route)
 
Within 1 month
Past medical history
 
Within 1 month
PATIENT APPOINTMENT INFORMATION
Email
Print
 
MISSED APPOINTMENT GUIDELINES
Please contact the program 24 hours in advance if you need to cancel or reschedule an appointment
Please contact the program 24 hours in advance if you need to cancel or reschedule an appointment
 
HOURS OF OPERATION
Monday: 8:00 am - 4:15 pm
Tuesday: 8:00 am - 4:15 pm
Wednesday: 8:00 am - 4:15 pm
Thursday: 8:00 am - 4:15 pm
Friday: 8:00 am - 4:15 pm
   
 
ADDRESS
28 Oki Drive NW
Calgary Alberta
T3B 6A8
PATIENT APPOINTMENT INSTRUCTIONS
  • Bring your Alberta health care card and a piece of government issued photo ID.
  • Check in at reception 15 minutes prior to your scheduled appointment time.
  • You may bring a family member or significant other during your consultation.
  • Please make sure to notify team if unable to communicate in english or have someone with you if you.
  • Bring your Alberta health care card and a piece of government issued photo ID.
  • Check in at reception 15 minutes prior to your scheduled appointment time.
  • You may bring a family member or significant other during your consultation.
  • Please make sure to notify team if unable to communicate in english or have someone with you if you.
 
DIRECTIONS
Located on Oki Drive NW.
Located on Oki Drive NW.
 
PHONE
403-955-7281
 
PARKING INSTRUCTIONS
Paid parking is available on site.
Paid parking is available on site.
 
EMAIL
VIRTUAL APPOINTMENT INFORMATION
 
 
WHEELCHAIR ACCESSIBILITY
Yes

This facility is wheelchair accessible and has an elevator on site


The primary purpose of the All Locations list is to let the user easily access any location of a healthcare service without going back to the main search screen.

The locations listed have 3 background colors:
  • Green means the healthcare service@location has referral information attached to it.
  • Brown means the healthcare service@location never had referral information attached to it, or it has unpublished referral information.
  • Red means
    • IA changed the healthcare service@location's status to something other than Current
    • It was deleted if it is an ARD healthcare service@location.
Green  and Brown are always at the top of the list. These are the Healthcare Service@Locations with the status of Current.
The Red list at the bottom consists of non-current Healthcare Service@locations that once had Published referral information in the ARD.
If the referral information was never published in ARD the Healthcare Service@location will not show in the Red list.

The secondary purpose of the All Locations list is to allow ARD Administrators to recover (copy) referral information from the non-current Healthcare Service@Locations to ones that are current.

Common Scenario:
A Healthcare Service moves from one location to another. In this case the IA Healthcare Service@Location record will be made defunct (non-current) and a new Healthcare Service@Location record will be created with a current status. In this scenario the captured referral guidelines in ARD can become "orphaned" as they are not attached to any current IA healthcare service.

Categories of non-current or orphaned referral guidelines: INDIVIDUAL and COMMON.
The REFERRAL GUIDELINES section of the profile has the prefix INDIVIDUAL or COMMON to help you choose the method below when transferring referral guidelines from a non-current Healthcare Service@Location to a current healthcare service@location.

Individual referral process
  1. Click on a non-current (Red) Healthcare Service@Location at the bottom of the All Locations list.
  2. The non-current referral info is displayed with the link Copy this Referral Process to another Healthcare Service@Location link on the upper right hand corner. Click on the copy link.
  3. Choose a current location (Green or Brown) from the All Locations list. This will be the Healthcare Service@Location you are pasting the referral info into.
  4. The system will display the Edit Referral Info screen populated with the referral info from the non-current Healthcare Service@Location you viewed in the first step.
  5. Click Save and the referral info is transferred from the non-current Healthcare Service@Location to the current one.
  6. Repeat these steps for each Healthcare Service@Location that needs attention.

Common referral process - 2 sub cases.
Case 1: At least 1 current Healthcare Service@Location with common referral info is with current status for this healthcare service; One or more Healthcare Healthcare Service@Locations where replaced by new one.
  1. Click on any current Healthcare Service@Location whether it has referral info (Green) or not (Brown).
  2. The healthcare service location opens in the Edit Referral Info screen populated with the current common referral info.
  3. Save it. 
  4. All locations will be updated with the common referral information, including all the locations that don't have referral info yet (Brown). The non-current referrals (Red) will also be updated.
Case 2:  All Healthcare Healthcare Service@Locations for a healthcare service are set to a non-current status and replaced by new ones. In this case there is no current additional referral info to copy from, so the only alternative is to pick up the non-current common referral process (Red). Follow the steps described in the section Individual Referral Process above to copy/paste the non-current common referral info to the current healthcare service locations.
Generally we want to replicate current common referral info to new or replaced healthcare service locations. We only resort to copying non-current common referral info if there is no other option.

Remember: Some fields can be location specific with the common referral process:
Parking Instructions, Directions, Parking Map, Wait Time, Referral Phone or Referral Fax.
To update these items you have to edit each Healthcare Service@Location separately.

ADDITONAL NOTES:
  • The info icon after the All Locations drop down will be visible to ARD Administrators.
  • The system doesn't allow you to copy referral information from one non-current Healthcare Service@Location to another.

 

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