Complex Care
Complex care at Bruyère Health 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.
Short-term complex care
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.
Long-term complex care
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.
Low intensity rehabilitation
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 Health 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