Complex Continuing Care

Bruyère is the sole provider of complex continuing care in Ottawa.

Complex Continuing Care is a specialized program of care for medically complex patients who require a hospital stay; regular on-site physician/ nursing care and assessment; and active care management by specialized staff. This program aims to improve and maintain function for patients with complex care needs by providing them with required services, support and a possibility of transition back to the community.

The interprofessional health care team works closely with patients and families to develop an individualized care plan. The care plan is continuously adjusted and evaluated as the patient’s care requirement changes. Our goal is to meet each client’s physical, emotional, social and spiritual needs, thereby achieving an improved quality of life. In keeping with our mission and values, we welcome the rich diversity of patients referred to us, as well as the dedicated staff, volunteers, physicians and students who care for them.

Complex Continuing Care at Saint-Vincent Hospital has three major care streams: specialized complex care, restorative care, supportive care. The common admission requirement for all three streams is that patients are dependent on others to complete their activities of daily living; specifically bed mobility, transfers, toileting and feeding. Each stream also has specific admission requirements. Patients will be moved from stream to stream as their care requirement improves or changes. Once a patient no longer needs Complex Continuing Care, the interprofessional team will ensure efficient and appropriate discharge into the community.

Specialized complex care

Patients in the specialized complex care stream have a progressive disease and multiple medical conditions that require ongoing monitoring by an interprofessional team. The specialized complex care stream also includes:

• Chronic Assisted Ventilator Care patients who have chronic respiratory difficulties and require permanent ventilator care, and
• Dialysis patients who have chronic renal failure and require hemodialysis or peritoneal dialysis.

Low intensity rehab

Patients in the low intensity rehab stream:

• Require an interprofessional care plan aimed at functional improvement over an extended period of time, with the goal to be discharged to another program or to the community; and/or
• Need specialized wound care for extensive surgical, vascular or pressure ulcers, with the goal to bring the wound to a level of care that can be managed in the community.

Complex medical care

Patients in the complex medical care stream:

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

Discharges and transfers

When a patient is no longer in need of, or has completed the treatment offered by the program to which he/she was admitted, the team will assist him/her as necessary in planning the discharge to an appropriate and safe environment that will meet his/her needs.

When a patient no longer needs complex continuing care, or has completed the treatment offered, the interprofessional care team will assist the patient in arranging the care and services that are necessary, whether the patient is returning home or moving to another facility. The discharge planning process will be completed in a timely manner in keeping with Bruyère discharge policies and the Ministry of Health and Longterm Care regulations where appropriate. Patients are responsible for their own discharge transportation.

Provincial referral form

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

For more information, contact

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