The Complex Care Program Ambulatory (CCP-Amb) stream 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.Ambulatory Complex Care Program (Amb-CCP) is a stream that provides comprehensive support for patients who receive care in the hospital, community, or at home. The Amb-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 Amb-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. Amb-CCP requires active participation from the patient’s care team(s) (e.g., social work, physician, family, school team).
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