Learn more about the Complex Care Hub and our support for your patients in the program
November 1, 2019
The CWC PCN has expanded our capacity to transition patients back to you from the Complex Care Hub (CCH) and recorded a new podcast episode with information about the service.
Starting in September, the PCN dedicated a second Registered Nurse specializing in acute and complex care to liaise with the program and provide patients of members with community case management.
When your patient is discharged from the CCH, one of the two RNs will:
- Contact you and keep you up to date on any changes
- Assess the patient at home and followup regularly during the transition of care
- Ensure the patient has access to the necessary services and help them manage the complex system of supports
Prior to discharge, the RNs stay current on your patients in the CCH by participating in case conference calls and conducting rounds with the program.
New Examiner podcast episode
To hear directly from the clinicians involved, listen as Roma Thomson speaks with Dr. Michelle Grinman, originator of CCH in the Calgary Zone, and Kim Wrubleski, one of our two RNs liaising with the program.
About the Complex Care Hub
The CCH provides community-based, hospital-level interventions to older patients with chronic, complex comorbidities who are at risk of hospital admission.
Based on the hospital-at-home model, it allows eligible patients to sleep in their own bed while getting the interventions they need. Patients in the CCH receive care from a General Internal Medicine physician and Nurse Navigator in a day clinic, and from Community Paramedics overseen by the physician in their own home.
The program operates out of the Rockyview General Hospital and South Health Campus. Non-urgent patients who seek treatment at either hospital’s ER are triaged as normal and, if it is determined they would benefit from short-term hospital-level care, screened for eligibility for the program. Existing in-patients are also screened.
The CCH team notifies you if your patient is admitted and sends a fax and verbal report upon discharge.
- Low acuity health problem
- Clinically and hemodynamically stable
- Able and willing to consent to the program
- Functionally, behaviourally, medically safe for care at home
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