Complex Care

Complex care at Bruyère is enhancing quality of life, helping people improve or maintain function and transition out of hospital and into the community. Regular on-site physicians, nurses and specialized staff provide care management and support for patients with complex medical needs.

In keeping with our mission and values, we welcome the rich diversity of patients referred to us and that of our care teams to create inclusive environments for everyone we care for.

Complex care planning

The interprofessional health care team made up of nurses, personal care assistants, social workers, physiotherapists, rehabilitation assistants, registered dietitians, occupational therapists, speech & language pathologists and physicians work closely with patients and their loved ones to develop individualized care plans. In the development of these plans, our patients and their loved ones are our partners in identifying the goals care that will help enhance quality of life at any stage.

The care plan is continuously adjusted and evaluated as the patient’s care needs change.

Complex care streams

Complex Care has two major care streams, each with their own admission requirements:

• short-term complex medical including low intensity rehabilitation and wound care
• long-term complex medical including ventilator care and dialysis

The common admission requirement for both streams is that patients need the support of others to complete their activities of daily living including: bed mobility, transfers, toileting and feeding.

Patients can transition between the complex care streams as they regain function and mobility and require less support and are able to complete activities of daily living more independently.

Once a patient no longer needs complex care provided, the care team will begin working on a discharge plan to home or to another care facility that will best meet their needs.

People referred for short-term complex care are living with complex illnesses or medical conditions. Our care teams work alongside our patients to avoid further loss of function and increase the ability to support day to day living. Patients with short-term complex care needs stay for an average of 90 days and receive:

• care provided by an interprofessional health care team, and
• a higher level of care than what can be provided by community agencies or long-term care homes.

Patients in the long-term complex care are living with chronic disease or a medical condition that needs ongoing monitoring by an interprofessional team. Our goal is to help maintain, slow the rate of, or avoid further loss of function over an extended period of time. The long-term complex care stream also includes:

• Chronic assisted ventilator care patients who require permanent ventilator care, and
• People who have chronic renal failure and require hemodialysis or peritoneal dialysis.

Patients receiving low intensity rehabilitation share a common goal to transition home or to another care setting in the community. People are referred for low intensity rehab when they need:

• An interprofessional care plan with a focus on functional improvement over an extended period of time
• specialized wound care for extensive surgical, vascular or pressure ulcers.

A palliative approach to care when needed

People receiving complex care at Bruyère benefit from expertise in our palliative approach to care that helps manage pain symptoms and improve quality of life.

Did you know that palliative care treats people with complex illness at any age and any stage and not just at end of life? A palliative approach to care can:

• Improve quality of life
• Reduce or relieve symptoms
• Help you make important decisions
• Provide support to you and your loved ones throughout your illness, from the time of diagnosis

Graduating from complex care – the discharge process

Planning to leave the hospital begins soon after you are admitted. Our goal is to provide care and help you transition home, or to another setting that can best meet your care needs. When you no longer need the level of care provided at Bruyère, your care team will begin preparing for your discharge.

We know that preparing for discharge, either to your home or to another care setting, can feel confusing and overwhelming, especially at the beginning of your care journey. To help ease some of those feelings, your care team will work with you, your loved ones and/or substitute decision maker to provide the best plan possible for your safe transition.

We practice a home first approach where we try to help you return to your home in the community. This will not be possible for everyone. Some will require additional care at home or need to go to another care setting, including a long-term care home where the level of care needed can be provided.

If you need care at home, Home and Community Care Support Services will talk to you about your care needs while you are in the hospital and about the resources in the community that may be right for you. They may contact you virtually (by phone) or in person, depending on your situation.

Ask your health care team for more information.

If your needs can best be met in a long-term care home, your care team and a placement coordinator from Home and Community Care Support Services will work with you to find a home that meets your care needs. This may include a temporary placement in a long-term care home where you will wait until a space becomes available in your preferred home.

For more information on transitioning to long-term care in Ontario see here.

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Provincial referral form

To refer, please complete this form, encrypt it, and email it to BruyereClinicalAdmissions@bruyere.org or fax 613-562-6095.

Clinical Admissions Coordinator
Saint-Vincent Hospital
60 Cambridge Street North
Ottawa, ON K1R 7A5
Tel.: 613-562-6262, ext. 4050