Photo caption: Erica Siebert, Integrated Service Consultant with the Extensive Needs Service at McMaster Children’s Hospital.
For children and youth with complex health needs, fragmented health systems have led to repeated emergency department visits, caregiver burnout, and gaps in care. In Ontario, a strategic partnership has pioneered a first-of-its-kind model to better support these families.
In 2023, Hamilton Health Sciences’ McMaster Children’s Hospital (MCH), CHEO and Holland Bloorview Kids Rehabilitation Hospital launched the Extensive Needs Service (ENS). Backed by the Ministry of Health and the Ministry of Children, Community and Social Services, this collaborative model is an opportunity for health system transformation.
ENS provides tailored wrap-around clinical supports to vulnerable children and youth with urgent and complex medical, developmental, and social challenges, and their families.
At MCH, 653 patients have accessed the program since April 1, 2024, demonstrating shorter inpatient stays, fewer school absences, and decreases in caregiver stress.
MCH delivers ENS through a community partnership framework. A network of local providers in Hamilton, Niagara, Haldimand-Norfolk, and Brant-Brantford brings rehabilitation, mental health and social services directly to families. Embedding clinical liaisons in these regions enables capacity building and tailored care to meet local needs, and also reduces travel burdens and fosters continuity for families.
Central to ENS is a commitment to personalized, trauma-informed and family-centered care. These principles are exemplified in the integrated service consultant (ISC) role. At MCH, ISCs operate in both outpatient and inpatient settings, guiding families through the continuum of care.
Acute ISCs work alongside the hospital’s multidisciplinary teams to prepare for admissions and streamline transitions into inpatient units. This includes physicians, psychologists, surgeons, social workers, child life, and others.
They also support discharge planning, liaising with community service providers across the province to develop individualized transition plans and bridge potential care gaps back at home.
One of MCH’s two acute care ISCs, Erica Siebert, describes the ISC mandate as “leading from behind,” ensuring that every clinical decision supports the patient’s unique needs.
Siebert’s team embeds the principles into daily practice: briefing clinical teams; orchestrating timely follow-ups with specialists; coordinating transitions to community services; and much more. This proactive coordination fosters trust and empowerment for caregivers often overwhelmed by complex systems.
“ENS patients are complex and don’t fit into a box, and by the time they get to us, they have typically leveraged all options,” says Siebert. “They need wrap-around care, and ISCs find the nuances to inform an integrated plan within the hospital and after discharge.”
A recent case illustrates the model’s emotional and clinical value.
Siebert recalls a family with negative past hospital experiences arriving for an emergency assessment, feeling anxious about the visit. Because the ISC team had developed a tailored plan with the family in advance, the emergency department was able to create a safe environment for the child, reducing agitation and facilitating smoother assessment.
From the moment they walked through MCH’s doors, the team was aligned, and the family felt genuinely supported.
“It’s true collaboration,” says Siebert. “Everyone brings their skills and expertise to understand what the patient needs, and the feedback we’ve received has been positive.”
Another unique element of MCH’s ENS program is the Family Check-Up program. MCH is the first Canadian hospital to embed this program across multiple services, offering tools for families to build resilience, navigate challenges, and restore confidence. To date, 68 families have been supported by this program.
Evaluation of ENS confirms significant reductions in emergency department visits and caregiver burden. Clinicians report enhanced interprofessional collaboration, more efficient use of resources, and greater alignment among teams.
Siebert notes that it’s “been neat to see progress, the shift in aligned goals, and the level of patient interaction.”
Families consistently describe ENS as transformative, noting that they feel supported across every step of their journey. ENS is enabling collaboration, co-design, and co-implementation across communities, partners, and government to address needs across the health system.
“It’s such a privilege to work on this program, and I’m quite honoured,” says Siebert.
Moving forward, MCH and its partners are scaling ENS’ infrastructure, expanding capacity, and strengthening community alliances to reach more children and families across Ontario.