Photo caption: The Extensive Needs Service team at CHEO.
Children and youth with complex needs often face a complicated health system that delivers fragmented care. This can lead to delayed support that often doesn't meet patients' unique needs, repeated ER visits, and ongoing stress for caregivers.
Recognizing this challenge, CHEO, Holland Bloorview Kids Rehabilitation Hospital and McMaster Children's Hospital have formed a strategic partnership to deliver the Extensive Needs Service (ENS) — an Ontario first, and a care model that has caught the interest from other health organizations across Canada.
Through collaboration within ENS, CHEO provides uniquely integrated specialty care to children, youth and families by running a community medical clinic and specialized “pods," teams that provide wrap-around care in one place.
Jointly funded by the Ministry of Health and Ministry of Children, Community and Social Services, this program provides wrap-around clinical, tailored support to vulnerable children and youth in Ontario at the right time, in the right place. Since launching in April 2023, over 2,000 children and youth have received care through this unique program across the three hospitals and their community partners.
This is a model that is more than collaboration — it can be a blueprint for a health system transformation that can deliver timely care that's personalized, accessible and equitable across the province and the country.
ENS at CHEO features interdisciplinary “pods" — teams that include behaviour therapists, a behaviour analyst, a respite worker, a social worker, a child & youth counsellor, and a service planning coordinator all working together at one location.
“Instead of a family bouncing from one team to another, they are simply attached to one pod and that pod contains all the skills needed to wrap care around the child," said Taylor Johansen, director of Neurodevelopmental Health at CHEO.
This collaboration and integration are a core part of CHEO's developing model of care as it readies for the opening of the new Integrated Treatment Centre, scheduled to happen in 2028.
Like this new treatment centre, the ENS team is providing care outside the wall of the main CHEO hospital building.
As of September 2024, ENS services expanded to a clinic at one of CHEO's community sites in Ottawa. The clinic provides physical assessments, medication review and support, access to medical services, tests and treatment, as well as clarification on diagnoses.
Photo caption: Hunter Nicholas, a CHEO patient who received services from ENS.
Hunter Nicholas, 13, lives with autism and has an extreme needle phobia. That means getting his annual vaccines has been traumatic.
His mom, Ananda, wanted a better solution, and she found it at the weekly clinic run by ENS in partnership with family physician, Dr. Nicole Shadbolt.
The clinic's collaborative format provided more support, tools and understanding for kids like Hunter.
“For the first time ever, my son didn't get upset when he got his shots," said Ananda. Hunter, who received three different immunizations, came home talking calmly about the experience and even smiled, saying the nurses were “nice." "After he had gone to bed, I had a little happy cry about it," she added.
Ananda Nicholas says the process was smooth and reassuring, from pre-clinic phone calls through the post-immunization support.
The ENS program at CHEO continues to transform challenging medical experiences.
The clinic, which is also unique because of support from a registered behaviour analyst, is aimed at patients who may have difficulty accessing medical care in traditional ways because of challenging behaviours or complex needs.
Other services include examining any medical reasons for certain behaviours, the ability to diagnose and assess medical conditions for kids with complex neurodevelopmental disorders and/or mental health conditions that need ENS wrap-around care, immunizations, and ordering medical interventions like blood work or medical imaging.
The clinic has become an additional, but important, resource for families whose children and youth receive ongoing care from CHEO's Neurodevelopmental Health team.
CHEO hopes to add more clinic days with a nurse practitioner to provide care to more kids and continues to welcome feedback from families to help shape the clinic's evolution.